Taunton PET CT

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• 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.

Patient areas were safe, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There had been 13 incidents relating to radiation since January 2025. The service reviewed and investigated safety incidents and events when things went wrong. Staff knew what incidents to report and how to report them. Staff received feedback from investigation of incidents and these were discussed at team meetings. A recent incident included a patient receiving the wrong radiopharmaceutical, which highlighted some confusion around the protocol applied to the scan. We saw actions were disseminated to staff and a log was kept confirming protocols had been read and understood. No patients or staff had come to harm as a result of these incidents. At our previous inspection we found learning was not always shared to ensure action was taken to improve safety. At this inspection we found this had improved and staff were aware of learning from incidents across multiple sites.

The service had access to 2 medical physics experts (MPE). One for computed tomography (CT) and another for the positron emission tomography (PET or radiopharmaceutical) side of the service. PET is an imaging test that is commonly used to look for cancer in the body. Both were informed of any radiation incidents reported. In collaboration with clinical staff, MPEs investigated and determined what radiation incidents met the threshold to be reported externally.

Staff understood the duty of candour. They were open and transparent and gave patients and families an explanation if and when things went wrong. This was done verbally when patients had not experienced moderate harm or above. Formal written duty of candour was only carried out when patients had experienced moderate harm or above. This was established through all reported incidents and the risk assessments associated with these.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The service carried out comprehensive risk assessments for people who used services and risk management plans were developed in line with national guidance.

There were clear pathways for the management and escalation of deteriorating patients within the department. The service was located within the grounds of an NHS trust. Staff were able to obtain immediate assistance by activating the NHS trust internal emergency call system if a patient became unwell and required transfer to the hospital or emergency department.

There were processes to ensure the right person got the right radiological scan at the right time. Staff filled out a pre scan safety questionnaire which included a 3 point check of identification in line with the society of radiographers guidance. At our previous inspection we found 3 point checks were not being performed for every patient before administering injections or scanning the patient. At this inspection we found these forms were audited and any areas of noncompliance were followed up. The last audit in October 2024 showed 100% compliance.

Staff followed national guidance for pre-scan pregnancy checks that could be potentially harmful to unborn babies. Inclusive pregnancy checks were undertaken, recorded and audited as part of an annual audit programme.

The radiation protection advisor (RPA) and the medical physics expert (MPE) were easily accessible for providing radiation advice. The service had appointed radiation protection supervisors (RPS) in the department which used ionising radiation. The clinical lead led as RPS with other members of the team deputising in their absence.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. There were clear processes to escalate unexpected or significant findings both at the examination and upon reporting. Reporting radiologists were onsite and accessible to staff for advice. The service had processes to direct patients as to what to do if they had a complication post procedure.

The service ensured imaging requests included the relevant information to allow for requests to be justified by a radiologist. Protocols for each request were recorded against the referral for both the technologists and radiographer to access. Patient information was transported with patients when attending a scan or procedure, such as do not attempt cardiopulmonary resuscitation (DNACPR).

As part of the justification process to carry out an exposure to radiation, the service used previous images of the same patient, even if these had been taken elsewhere.

There was secure transfer of data from the scanner to the providers own central picture archiving and communication system (PACs). From there, a dedicated team sent images on to the trust’s PACs.

The service ensured that the requesting of an x-ray or other radiation diagnostic test, was only made by persons in accordance with IR(ME)R (the regulations to make sure that it is used safely to protect patients from the risk of harm when being exposed to ionising radiation). The service held a list of approved referrers, both medical and non-medical.

All staff completed safeguarding training, including safeguarding adults and safeguarding children and young people. At our previous inspection we found levels of safeguarding training had not been specified. At this inspection we found this had improved and staff were trained at a minimum of safeguarding level 2 with 1 member of staff trained in safeguarding level 3.

Although there had been no reported safeguarding concerns in the last 12 months, staff we spoke with knew how to make a safeguarding referral. There was a named safeguarding lead.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Information was collected by the bookings team and staff accessed patient care records to look for any information about reasonable adjustments which might be required for each patient. Staff filled out a pre scan safety questionnaire which included a 3-point check of identification in line with the Society of Radiographers guidance. The forms were audited centrally, and any areas of noncompliance was followed up.

Staff attended a daily huddle to discuss; staff wellbeing, manager availability, scheduling issues which may impact vulnerable patients, medical emergency management, health and safety concerns, equipment issues, daily checks, supervision and resuscitation trolley checks.

The service had clear local rules and employer’s procedures which protected staff and patients from ionising radiation. We saw printed documents had version numbers to show when the policy had been updated.

The radiation protection advisor (RPA) and the medical physics expert (MPE) were easily accessible for providing radiation advice.

The service ensured that patients and staff who were confirmed pregnant or possibly pregnant, always informed a member of staff before they were exposed to any radiation. Inclusive pregnancy checks were undertaken, recorded and audited as part of the annual audit programme.

Imaging requests included the relevant information to allow for requests to be justified. All requests were justified by a radiologist. Protocols for each request were recorded against the referral for both the bookings team and technologists and radiographers to access.

Staff had undertaken training to manage and contain unintended spillages of radioactive substances. Training data provided showed all staff required to complete this training had done so.

The service offered some weekend services for specific types of scans. There was a member of the senior leadership team on call over the weekend to escalate any emergencies.

The service monitored staff for radiation exposure. Most staff working in the service were classified workers and had to have a dose report to present at their annual medical. Staff told us if there was an increased dose on any report, senior staff would discuss it with them. However, staff we spoke with did not know if they had been given their annual dose reports.

Resuscitation equipment was readily available and there was evidence of regular review, although the documentation was not always clear. We saw that tamper evident tags did not have reference numbers. We were told this was a change made by the NHS trust who maintained the trolley. We raised this at the time of the inspection, and this was escalated to the NHS Trust.

The service did not monitor unshielded waste bags in the hot lab at the time of disposal. This meant there was a risk staff could be exposed to radiation if contamination had occurred during the radioactive injection as they did not monitor bags until the end of the working day. However, staff disposed of radioactive waste in line with legal requirements. Radioactive sharps bins or waste bags were stored in lead shielding and monitored until radiation decayed to a safe background level, at this point the waste was disposed of normally. We saw records of this which were up to date and fully completed.

The design of premises kept people safe. Examination rooms were spacious and allowed distancing between staff and patients once they had received their radioactive injections. The imaging service ensured that non-ionising and ionising radiation had arrangements to control the area and restrict access. This included warning lights and swipe access doors. There was clear signage where ionising radiation exposures occurred.

The service ensured specialised personal protective equipment was available and used by staff and carers when needed. Lead aprons, lead screens were checked annually for their integrity.

There was a clear process for maintenance of equipment, reporting of any faults and handover to and from engineering staff which included a summary of any work done. Engineering support was supplied through formal maintenance contracts where staff could access scanners and systems remotely and onsite where necessary.

The service had backup generators to ensure the running of essential equipment in the event of power failure.

Staffing levels and skill mix were planned so patients received safe care and treatment, and staff did not work excessive hours. Scanners were staffed by 2 staff plus the clinical lead. The service operated 12-hour days, 6 days a week.

The service did not use agency staff and utilised its own bank staff. This enabled the same staff to consistently work at the site. These staff received comprehensive inductions and training.

There was a clinical lead and a radiation protection supervisor (RPS) on site. If the clinical lead for the site was not available, another clinical lead from alliance medical services would step in.

Staff could contact a radiologist for advice. Radiologists were present on site daily and available by telephone at the main hospital. The service had a list of additional radiologists who could request and report scans for the service by means of delegated authority from the administration of radioactive substances advisory committee (ARSAC) licence holder.

Staff had received and were up to date with appropriate mandatory training. At our previous inspection we saw training modules including dementia awareness training, Mental Capacity Act, Deprivation of Liberty and Ionising Radiation (Medical Exposure) were not mandatory training subjects. At this inspection we found this training was now mandatory, and the service had 100% compliance. The service ensured relevant staff continued registration with relevant bodies and gave support with revalidation where necessary.

There were arrangements for supporting staff which included one-to-one meetings, coaching, clinical supervision and revalidation. Staff were encouraged and given opportunities to develop. Staff attended a variety of courses and had access to both online and face to face specialist training from a national cancer hospital.

Precautions were taken when seeing people with suspected communicable diseases. Staff explained patients seen in the service were often cancer patients, so it was vital infectious patients were kept separate in case of patients who might be immunosuppressed. In the event of a patient attending with an infectious disease, staff had access to an onsite cleaning team. If a patient was vulnerable, staff explained they would book those patients towards ends of lists to minimise contact with other patients.

Staff adhered to infection prevention control principles. The annual infection prevention and control audit was completed in February 2025. This included hand hygiene, environment, waste management, spillage and PPE. The service scored 99% compliance.

All areas we visited were clean and records we saw were complete. Staff had access to showers and onsite changing facilities.

Arrangements for managing waste and clinical specimens kept people safe. This included classification, segregation, storage, labelling, handling and treatment and disposal of waste.

Staff followed good practice in medicines management. Medicines were ordered, transported, stored and disposed of safely, including contrast agents and oxygen cylinders. Radiopharmaceuticals were prescribed, ordered, administered and stored in line with best practice and relevant legislation.

Radiologists held 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. At our previous inspection we saw the documents giving authority to order and inject radiopharmaceuticals still referred to the old Administration of Radioactive Substances Advisory Committee certificate number. This meant important documentation was not reviewed and updated at a corporate or local level. We reviewed the license for the unit at this inspection and found it was in date. Information reflected the examinations undertaken with a clear line of delegation for injecting radiopharmaceuticals.

The service carried out medication allergy and safety checks prior to all scans. This information was written down and stored on the radiology computer system. The radiology computer system allowed staff to add a warning flag which alerted staff to previous reactions and other allergies.