Poole PET-CT Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. The service had a current incident reporting and image reviewing policy, which reflected both the provider and national guidance. Staff recognised and reported incidents and near misses in line with the local procedure. We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. The service had an electronic system for managing incidents. Staff told us they were able to identify and report risks, and they were confident these would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harms occurring. There had been no (zero) reported Never Events in the preceding year. Never Events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. Incidents were analysed to identify trends or themes and potential links to individual practitioners. There had not been any repeated themes or trends in the year prior to our assessment. Managers ensured actions from patient safety alerts were addressed and progress was monitored.

Managers debriefed and supported staff after any serious incident. There was evidence changes had been made because of feedback. For example, an incident had occurred in the reception area during a period where the reception desk was not staffed. This meant the emergency response was delayed. Whilst this was not a cause of the incident, the service increased staffing cover of the reception desk as a result.

Clinical staff completed training on recognising and responding to patients with for example, patients with mental health needs, learning disabilities and dementia.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed prior to the diagnostic imaging and all images were based on a formal request from a member of the medical team.

The service provided PET-CT scans. The service ensured the ‘requesting’ of a PET-CT scans were only made by staff or persons in accordance with Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) 2017 (IR(ME)R). All referrals included patient identification, contact details, clinical history and examination requested, and details of the referring clinician or practitioner. The service held a list of approved referrers with example signatures. This meant any requests received from persons not on the list were immediately escalated by leaders for clarification.

There was an inclusion criteria for both private and NHS patients.

For example, the service ensured staff were aware of patients of childbearing potential, who were or may be pregnant before they were exposed to any radiation in accordance with IR(ME)R and for staff in accordance with Ionising Radiation Regulations (IRR) 2017. We saw posters displayed in patient areas telling them to speak to a nuclear medicine practitioner before they were scanned. Additionally, the service did not scan anyone under the age of 18.

Patients requiring scans were given enough information to enable them to understand the procedure. The service had systems and processes to ensure the correct patients were treated throughout the patient journey and they only received the procedure which was intended. We walked the patient pathway and tracked patient care from admission to the department and discharge. Staff confirmed action to take was understood by them in the event of any concerns raised. Suitably skilled and qualified staff accompanied patients in all areas and undertook the required diagnostic procedure.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. The service used The Society of Radiographers “pause and check” system. We observed staff always used the 3-point demographic checks. Pause and check consisted of the 3-point demographic checks to correctly identify the patient, as well as checking with the patient the site to be imaged, the existence of previous imaging and for the operator to ensure the correct imaging modality was used.

All patients were required to complete diagnostic imaging safety questionnaires. The safety questionnaires included asking patients if they had cardiac pacemaker, defibrillators or were pregnant. We saw these were completed. Family members were asked to complete a visitor’s safety questionnaire prior to the scan. The service had an up to date pregnancy policy. Gowns were available for patients to change if their clothing contained metal, such as metal zips.

Patient records were a mixture of electronic and paper based and were kept securely. The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training, data provided by the service showed 100% compliance for both. There were current safeguarding policies, and these reflected the national guidance for adults and children, including where children were visitors. The service did not scan patients under 18 years old.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The registered manager had oversight of safeguarding within the service. Staff were aware of the central service Safeguarding Adults and Safeguarding Children Policies and referred to them if they had any safeguarding concerns. Safeguarding Leads’ contacts for the adjoining NHS trust and Alliance Medical were displayed in the unit.

Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies and staff knew what happened when they raised concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for visitors attending the department. The service had an up to date chaperone policy, which all patients were informed of when they attended the service.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patient to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. There were interpreting services available for those who needed them, this included languages spoken by the local community and British sign language.

The service worked with patients to understand and manage risks. The scanning process met patients' needs in a way which was safe and supportive.

Staff completed risk assessments for each patient on arrival. Patients completed the PET-CT patient data form which was a safety screening questionnaire to ensure they were suitable to be scanned and enter the PET-CT environment. We observed patients completing this form with staff.

The service ensured radiation doses were kept as low as reasonably practicable. Doses for each PET-CT scan were pre-defined and measured to ensure the correct amount of radiopharmaceutical was used for each patient. Dose reference levels were clearly displayed in the lab and registered manager undertook an annual audit of doses, to ensure they were within legal limits.

Radioisotopes were only drawn up once the patient was present. Audit records we reviewed confirmed staff accurately recorded the type and dose of radiopharmaceutical used as well as the name of who had administered it.

Staff stored and managed radiopharmaceuticals safely. Staff took delivery of radiopharmaceuticals up to three times per day. Staff received deliveries in line with the provider’s policy. Radiopharmaceuticals were stored inside a lead lined dispensing cabinet in a locked room. Only authorised staff could access the room.

There was one toilet, for patients and visitors to use before the patients had their injections. Another toilet was exclusively for patients receiving radiopharmaceuticals, this was to prevent the risk of unintended exposure to radioactive waste.

We spoke to 3 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care. For example, they told us staff had gone the extra mile to provide support.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design of the environment followed national guidance. The service had a preparation area, changing cubicles, a scanner and control room with the post processing and reporting area.

The design of the Positron Emission Tomography and Computed Tomography (PET-CT) unit took account of the restrictions on doses of radiation administered to patients and others. As such, individual cubicles were required for each patient to lie in after their injection. Staff had enough space to move freely through the department but were also able to maintain safe distances from radioactive materials and patients after they had received their injection. Patients who had received their radioactive injection had their own separate toilet to use to prevent contamination for staff and other patients. When a patient was accompanied by a family member, friend or carer for their scan, measures were taken to reduce environmental radiation exposure by spacing chairs at a safe distance to the cubicle.

The service ensured specialised personal protective equipment was available and used by staff and carers when needed. Staff showed us the syringe shields, lead screens and storage facilities for the radiopharmaceuticals. We saw how staff used them to dispense and administer injections safely to patients.

The radiation protection supervisor (RPS) audited the service for compliance with Ionising Radiation (Medical Exposures) Regulations (IR(ME)R). We saw evidence of the last audit from August 2025 and should be repeated annually in line with legal requirements under IR(ME)R 2017. The audit results showed full or partial compliance in all areas. Where improvements or actions had been identified these were documented, with a named lead.

The service monitored staff for radiation exposure using dosimeters. Staff wore one on their torso and a finger-based dosimeter when handling, drawing up and administering radioisotopes. Dose reports were reviewed by the registered manager on a monthly basis, and any high or outlying doses were discussed with staff. For example, if a member of staff had a high finger dose, they were offered additional support, observation and training in handling and injecting radioisotopes.

Risk assessments addressed occupational safety as well as considering risks to people who used services and the public. For example, doses of radiation to members of the public and to patient escorts, such as nursing staff. The service was also supported by the NHS Trust Medical Physics service to ensure radiation equipment was safe and doses well controlled.

Patients could summon assistance and help as needed and we saw how patients were shown this. The service had suitable facilities to meet the needs of patients’ families when necessary. The patient waiting area had wipe clean seats and a coffee machine as well as a television an WIFI available for relatives and patients who were waiting.

Staff carried out daily safety checks of specialist equipment. The PET-CT scanner underwent daily quality assurance checks and staff could describe what they would do if any of the checks fell outside of acceptable ranges. Other specialist equipment, such as Geiger counters and calibration devices, were checked daily and serviced annually. A Geiger counter is a portable instrument used to detect and measure ionising radiation.

The design, maintenance and use of facilities, premises and equipment kept people safe. The service had enough suitable equipment to help them to safely care for patients and staff were trained to use them. The service ensured controlled areas (where ionising radiation was present) were restricted and clearly marked for access by authorised personnel only. Doors to the unit were locked with key code pads to prevent unauthorised admittance and there was a clear signage advising persons when radiation was present in scanning rooms. We observed staff and patients only walking into the secure patient area when permitted to do so.

Local safety rules were in place and reflected best practise. We saw these had been read and acknowledged by all staff. Handover signage and forms were used when equipment was handed to engineers and physicists for servicing and testing, this reflected guidance and best practice.

There was suitable equipment provided to support patients who needed this, for example for patients who needed assistance with their mobility or to transfer onto equipment. Staff carried out daily safety checks of specialist equipment. Resuscitation equipment was readily available. The unit had two emergency kits available, one of which was maintained by the hosting NHS Trust. We checked the contents of the resuscitation trolley and emergency bags and found everything listed was present and in date.

The environment used for patient care reduced the risk of patient harm, and included for example, safe flooring, handrails and window restrictors. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the trust policy. Hazardous substances were stored safely and information about products was available to staff.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

Diagnostic imaging procedures were only carried out by professionals with appropriate seniority and speciality training. The service had enough diagnostic radiographers with nuclear medicine training and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

Once the patient had their scan, all images were uploaded centrally to the Alliance Medical picture archive communication system and redirected from headquarters back to the practitioner license holder for reporting. There was a dedicated team centrally who oversaw and checked all images were sent withing the seven-day target under the NHS England Cancer contract. For NHS patients medical staff employed by the host NHS trust reported on their scans.

New staff had a full induction tailored to their role before they started work. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. All radiologists were required to provide evidence of appraisal and re-validation.

Bank workers had a local induction to the area in which they were working. For example, we spoke with staff who routinely worked at other services within the same provider group. They described how they had received local inductions and unit orientations in the different units they had worked.

The service provided mandatory training in key skills to all staff. The service recorded training details for the staff centrally which aligned with mandatory training required by the service. There was evidence all staff working with radiation had appropriate training in the regulations, radiation risks, and the use of radiation. Modules covering Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) 2017 updates were listed as mandatory. Managers monitored mandatory training and alerted staff when they needed to complete updates. Staff received and kept up to date with their mandatory training. The data showed a completion rate of 93%.

The service had a medical consultant on call during evenings and weekends. Staff could contact a radiologist or Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) practitioner licence holder for advice. As the centre was located in the grounds of an NHS trust, radiologists (as part of a service level agreement) were available during scanning hours.

Radiologists who reviewed and reported on scans had annual appraisals with the NHS Trust, these were then provided to Allied medical leaders to ensure they were assured they had been completed. Radiologists held appropriate IR(ME)R practitioner licenses for the administration of each radiopharmaceutical. These licenses were stored and coordinated centrally at the provider headquarters to ensure they were up-to-date and reflected the types of examinations being undertaken in the service. We reviewed the license for the unit and found it was in date. Information in them reflected the examinations undertaken with a clear line of delegation for injecting radiopharmaceuticals. We also saw the documents giving authority to order and inject radiopharmaceuticals referenced the correct licence certificate numbers.

Managers reviewed the number and grade of clinical staff, assistants and other key roles, needed for each shift in accordance with provider and or national guidance.

Patients spoken with felt their needs were met in a timely way and we observed staff attended to patients in a kind and supportive way. Patients appeared comfortable and were engaged in conversations with staff. Staff spoken to said they felt the service was safe. They were able to take breaks during their shift.

The service supported the learning and development needs of staff and made they received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. They supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. For example, we saw appraisal documentation where attendance at external training courses had been discussed to support the development of staff. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service managed infection risks well. Staff used equipment and infection control measures to protect patients, themselves, and others. Clinical areas were visibly clean and had suitable furnishings which were clean and well maintained. Staff had access to a provider-level infection and prevention and control (IPC) policy and supporting guidance.

Cleaning staff accessed the department out of hours, due to radioactive materials stored on site, and were restricted to general areas only. Areas where radioactive materials were kept, such as the injection preparation room and the waste storage cupboards, were cleaned by clinical staff. All restricted areas including waste storage areas were visibly clean and uncluttered.

The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas. For example, the IPC audit results from February 2025 showed 95% compliance against a range of audit measures that included hand hygiene, waste management and environment.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections. In all clinical areas we saw specialist cleaning wipes and saw staff using them to clean equipment between each patient scan.

Staff understood the process for managing spillage of radioactive material or body fluids in the department. The service had policies and procedures for the management of spillages. They also carried out regular spills scenarios that were documented for both audit and development purposes. We saw evidence of 3 radiation scenario events and the feedback generated. All of which demonstrated staff managed the scenario effectively.

We saw staff followed infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the service’s PPE standard operating procedure. Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

There were no incidents relating to healthcare associated infections in the 12 months before our inspection.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

Staff followed processes to prescribe and administer medicines safely. The service had processes to ensure the right radiopharmaceutical and activity was sourced, prepared and injected into the correct patient. Radiopharmaceuticals were ordered in advance and according to the individual request.

All administrations of radiopharmaceutical were performed under the written authorisation of an administration of radioactive substances advisory committee (ARSAC) license holder. An IR(ME)R Practitioner was always available when the service was operational. A list of IR(ME)R Practitioners was seen in the scan control room and staff said they were easily contactable.

Staff weighed patients on arrival to the centre to ensure the dose to be administered was calculated accurately.

Staff completed pre scan questionnaire to determine what medications and vaccinations the patient had received prior to the scan. Staff explained to patients the necessary safety precautions to take after their scan.

At the time of this assessment the service was not using and injecting contrast media as part of their scanning protocols.