Taunton PET CT

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The service worked effectively with other providers in its Cancer Alliance towards achieving local priorities on earlier and faster diagnosis, including rapid diagnostic and assessment pathways.

Staff could explain how they were working to deliver high quality care. The culture of the service was centred on the needs, experience and outcomes of people who used services. Patient feedback supported this and staff were genuine and caring in their approach to patients.

Staff felt supported, respected and valued which was reflected in the most recent staff survey results. There was a strong emphasis on the safety and well-being of staff with multiple newsletters, events and awards.

The culture encouraged openness and honesty at all levels within the organisation, including with patients, and in response to incidents. Leaders and staff understood the importance of staff being able to raise concerns without fear of retribution and gave an example of when external pressures had impacted on patient care which was addressed through open conversations with staff.

There were mechanisms for providing all staff at every level with the development they needed including high-quality appraisal and career development conversations.

There were processes and procedures to ensure the provider met the duty of candour. For example, staff were aware of their responsibilities and had received training. Duty of candour was given verbally to patients where the level of harm was not notifiable to CQC. Written duty of candour was issued when things had gone wrong and met the threshold of harm to be notifiable to CQC.

Staff were aware of the whistleblowing and freedom to speak up policies.

Leaders were new to the service and acknowledged there had been a long period of instability for the team prior to them joining. Leaders recognised it would take time to build trust with the team. New managers received a radiation induction. Leaders also valued their relationship with other leaders within the region and valued their knowledge and experience with clinical matters. Managers met every 2 weeks and attended an annual unit manager conference where leaders discussed the strategy and felt their ideas were listened to.

Staff told us leaders were approachable and listened to their concerns and suggestions.

There were leadership arrangements to support improvement of the services. For example, the service recently started using their own radiopharmaceutical on Saturdays. This meant the service could provide more scanning appointments.

There was a clinical lead who acted as main radiation protection supervisor (RPS) but all other clinical staff had undertaken RPS training to deputise in their absence. Clinical leads could speak with the head of clinical services through a live chat which could be accessed daily. There was a formal 6 weekly call and face to face meeting twice a year between the clinical leads and head of clinical services.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

There were freedom to speak up champions in the team. Freedom to speak up was a standard agenda item and was discussed in team meetings.

Staff were aware of the whistleblowing and freedom to speak up policies. The culture encouraged, openness and honesty at all levels within the organisation, including with people who used services, in response to incidents.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Staff were actively engaged so that their views were reflected in the planning and delivery of services and in shaping the culture. For example, the team held regular meetings locally and nationally.

Staff felt supported, respected and valued. Staff we spoke with felt positive and proud to work in the organisation.

There was a strong emphasis on the safety and well-being of staff. There was a monthly newsletter which celebrated staff achievements and feedback plus various other initiatives including health and well-being champions.

Equality and diversity were promoted within and beyond the organisation. Staff, including those with protected characteristics under the Equality Act, felt they were treated equitably which was reflected in the latest staff survey.

Staff were able to request reasonable adjustments and changes to working arrangements which were considered by managers.

There were effective, clear structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services. These were regularly reviewed.

The clinical leads held monthly clinical lead meetings. We saw from meeting minutes, quality and sustainability both received sufficient coverage in relevant meetings.

Arrangements with partners and third-party providers were governed and promoted coordinated, person-centred care. There was a comprehensive structure for reviewing contracts and service level agreements, such as discrepancies in reports or scan image quality. The service attended quarterly multiagency service reviews including with the local NHS trust, cancer nurses and the United Kingdom’s administration of radioactive substances advisory committee (ARSAC) licence holders.

Staff participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

There were clear service performance measures, which were reported and monitored through various performance dashboards. We reviewed internal documents including the quality assurance report for February 2025. The service scored 95% compliance for quality assurance.

There were arrangements to ensure that data or notifications were submitted to external bodies as required such as accidental or unintended exposures to radiation which are reportable to CQC.

Data showed 97% of staff had completed mandatory training. At our previous inspection we found governance arrangements for oversight of staff training were not accurate or effective. At this inspection we found clear arrangements for mandatory training compliance oversight.

Staff at all levels were clear about their roles and they understood what they were accountable for, and to whom. Organisational structure charts were clear.

Medical physics was sought through a third-party provider in the case of the PET element of the service, and CT was covered by the local NHS trust medical physics team. Staff reported good access to advice when they needed it and explained the teams were engaged and accessible.

There were regular radiation protection committee meetings with evidence in the minutes of actions and incidents feeding into the overarching governance structure and meetings. Minutes from meetings were detailed and captured broad range of discussion topics including radiation incidents, modality RPS reports and discussion of audits.

There was a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken.

There were arrangements for identifying, recording and managing risks, issues and mitigating actions. At our previous inspection we found the risk register was not reflective of the risks faced in the carrying on of the regulated activity. However, at this inspection we found the risk register was clear with stipulated risk owner and review dates.

There were comprehensive assurance systems, and performance issues were escalated appropriately through clear structures and processes. For example, reporting discrepancies.

There was 24/7 PACS support based at the main hospital site, and accessible through the main telephone switch board or by on-call telephone.

Systems that managed information about people who used services worked well and supported staff, carers and partner agencies to deliver safe care and treatment. All the information needed to deliver safe care and treatment was available to relevant staff in a timely and accessible way. This included test and imaging results, care and risk assessments, care plans and case notes.

Leaders engaged with external stakeholders, such as commissioners.

The service reviewed and investigated safety incidents and events when things went wrong. All relevant staff, services, partner organisations and people who used services were involved in these reviews and investigations.

Lessons were learned, themes were identified, and action was taken as a result of investigations when things went wrong. Learning from lessons was shared to make sure that action was taken to improve safety. Senior staff and medical physics staff attended dose optimisation meetings where discrepancies from dose audits were discussed, and actions identified.

There were effective arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations and reviews. Through governance group meetings, relevant safety alerts were disseminated through senior leaders down to teams for action.

The imaging service ensured that radiation incidents were fed into risk management structures, and accidental and unintended exposures were notified to CQC.

Systems that managed information about people who used services supported staff, carers and partner agencies to deliver safe care and treatment. All relevant patient information, including test and imaging results, care and risk assessments and case notes were obtained prior and shared post appointment.

There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs. The service held regular contract reviews with external partners where open discussion around performance and demand occurred.

Leaders and staff strived for continuous learning, improvement and innovation. The service participated in a variety of research projects, supported by the medical physics team. For example, the service was involved in a mixture of commercial and non-commercial cancer clinical trials using FDG. FDG stands for Fluorodeoxyglucose which is a radioactive glucose compound used in PET (Positron Emission Tomography) scanning. It highlights areas of metabolic activity in the body during imaging. FDG PET scans are commonly used to detect cancer and monitor various conditions. They were working alongside research and development departments to increase future research capacity.

The service had been assessed under the National Accreditation Body for the United Kingdom (UKAS) and received accreditation in the Quality Standard for Imaging (QSI) and the British Standard 70000. The latter included medical physics, clinical engineering and associated scientific services in healthcare requirements for quality, safety and competence for imaging services.