Trinity Medical Imaging

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We were told the initial assessment was based on the screening of referrals received by the service, which was managed by the Registered Manager (RM). The service's referral forms were available via their website, and referrers were encouraged to register with the service. Referrals for NHS patients under the care of the acute trust who contracted Trinity Medical Imaging services, were accepted only from staff within the trust’s radiology department.

The service anticipated that the referral information received would include details of any communication needs, including identifying when interpreting services were required. Any additional needs like mental health needs, disability support and carer involvement would also be provided within the patient’s referral information from the referring clinician. Referrals into the service provided information about the clinical indications for the scan request. In the event of queries, the RM would follow up with the referring clinician for more information, such as the rationale and appropriateness of the scan requests.

Although details for the exclusion criterion were not available on the provider’s website at the time of the assessment visit, we were told this issue was being addressed and the website would be updated within a month of the inspection team’s visit.

During observations of scanning patients and review of patients’ care notes, we found that patient consent was consistently asked both verbally and in written form, and these were recorded. We observed that staff discussed pregnancy risks with patients and documented patient feedback. It was noted that the presence of a carer with a patient during a scan was not documented in the patient’s care notes. But the patient’s verbal consent to their carer being present and the carer being shown and understanding of the radiation information sheet was noted. When we reviewed pause and check audit information submitted by the provider, it confirmed 100% compliance with this practice within the service between February 2025 to March 2025.

Patients and their relatives and/or carers were able to meet their hydration needs via the water fountain, or they were offered hot drink options by staff. There were also individually packets of biscuits available at the reception desk, and staff told us they could direct patients and their relatives to local facilities as the need arose.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation.

Following the inspection, the provider submitted evidence of multiple internal audits. These included hand hygiene audits, clinical and non‑clinical cleaning checklist audits. The provider submitted audits relating to specific clinical procedures, including CT dosage and Diagnostic Reference Levels (DRL), VQ administration audits covering the period 2023–2025, and performance audits relating to meeting referral‑to‑treatment key performance indicators for NHS-commissioned services. The service’s audits also showed where there were discrepancies and the action plan to address these. For example, the differences between local and average CT dose levels. In this way, the service demonstrated that it monitored practice and performance to support the delivery of safe and effective care.

Within the provider’s staff appraisal system, there were opportunities for the senior leaders to review staff performance, identify areas of both strength and weakness and to identify areas for staff development. This included facilities for staff to identify barriers to their development. It was noted that access to further training and/ or external training courses were themes. However, plans to address these shortfalls were not always clearly defined. For example, ‘the training and development plans’ and the ‘method of measurement’ to address these were not consistently completed within the staff appraisal forms. In this way, a clear plan of action was not always clarified and how the service would be able to measure success was not consistently defined.

The provider submitted evidence of appropriate medication-related audit and evidence of the resultant action plan, for improvements to the service. For example, the ‘administered dose audit’ in 2018 led to an improvement action plan and the inspection team observed that appropriate Diagnostic Reference Levels (DRLs) information was on display and easily accessible to clinical staff.

There were facilities for meeting patients and their carers/relatives’ nutrition and hydration needs. Information about the support required to meet patients’ needs relied on referral information and on patients or their relatives sharing relevant details during interactions with staff. Some policies we saw were out of the provider’s 5-year policy audit cycle. Such as the 'Mental Capacity Assessment Guidance & Checklist', dated 2017 and the Infection Control policy, dated 2018.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

When we visited we observed that information to guide staff on how to access to emergency interventions were clearly defined within the advice flow chart located at reception and within the associated provider policies, such as those related to management of medically unwell patients at reception and the emergency medications and resuscitation equipment.

The service’s electronic patient record (EPR) system did not interface with other systems, such as those used within the NHS. However, the service was able to access Radiology Information Systems (RIS) and was in the process of implementing Picture Archiving and Communication Systems (PACS). The provider told us that referral information was incorporated into the EPR system and used to identify patient needs, including communication requirements. Information from referrals and the screening process, undertaken by the Registered Manager (RM), was used to support coordination of care within the service.

Staff feedback indicated that they felt leaders were visible, supportive, engaged well and were accessible to manage clinical and operational issues. For example, the lead clinical Nuclear Medicine (NM) Technologist was on site daily and supported the day to day running of the service. Although the RM was on site once a week, they were reportedly available to staff daily via the staff communication and messaging system. Which was accessible to all staff via the site computer, and also via staff members’ personal devices, such as their mobile phones.

When patients from the hospital were seen at the service, their referral information was available to staff via the service’s EPR system. The patients were accompanied by the hospital staff escort. The service did not play a role in allocating the hospital staff escorts but would routinely supply the hospital staff escorts with radiation risk information in addition to any radiation risk information handover arrangements made externally by the responsible hospital.

The RM would take a lead role in liaising and consulting with referring clinicians, this would include liaising with GPs, clinicians within independent healthcare and others who made referrals to the service. For those patients referred by the acute NHS hospital who commissioned services from the provider, again, the RM would make contact with the referring radiologist, and there were quarterly contract meetings where the service’s performance was discussed.

We did not look at Supporting people to live healthier lives during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation.

The service undertook internal peer review of reporting between its three consultant radiologists, and these reviews were audited. Audit evidence submitted following the assessment visit covered the period from April 2025 to December 2025 and showed that radiologists reviewed each other’s reports and recorded outcomes, such as feedback or the addition of addendums. However, audit outcomes did not consistently demonstrate learning or improvement, for example where alternative imaging modalities may have been recommended but no record of formal discrepancy meetings was provided. There was no evidence of external independent peer review activity, and limited evidence of structured benchmarking to assess performance against similar services and inform service improvement. However, nuclear medicine (NM) technologists were encouraged to present at British Nuclear Medicine Society meetings, there was evidence of poster presentations and internal audits.

The Registered manager (RM) explained the audit programme and provided information on monitoring of performance indicators, including did‑not‑attend (DNA) rates, which were shared with the commissioning NHS trust. However, there was limited evidence to demonstrate how the audit findings were used to drive improvement or evaluate the effectiveness of actions taken.

Team meeting minutes showed that the RM attended weekly staff meetings and was responsible for reviewing incidents and managing complaints. However, staff were unable to describe recent incidents or past complaints, and meeting minutes did not demonstrate that learning from incidents or complaints were routinely shared to inform service development.

The service collected patient feedback through surveys, and data from April 2025 to March 2026 showed consistently positive patient experiences. However, there was limited evidence to demonstrate how feedback was analysed, acted upon, or used to inform measurable service improvement. Where patients identified areas for improvement, such as needing additional information or comfort measures during scanning, no clear action plans or outcomes were documented.

While patients and relatives consistently reported positive experiences of care, the service did not consistently demonstrate how performance information, incidents, or feedback were used to systematically monitor outcomes or drive continuous improvement.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

We found that patient consent was consistently asked both verbally and in written form, and these were recorded within their care records. Additionally, we observed that patients’ verbal consent to their carer being present or not was discussed by staff. During observed practice, a carer was present during a scan. The carers informed consent was gained, after the carer had been shown the services radiation information sheet and the carer understanding of the information confirmed by the treating clinician, this was noted in the patients care records.

When we spoke with patients and their relatives, they told us their consent had been sought prior to procedures, and their questions addressed by staff.

The services consent policy ‘Consent policy & Consent / Withdrawal of Consent Forms (2023), was reviewed. This was within the providers 5-year review date, was relevant to the service. Issues associated with mental capacity were mentioned in the consent policy, in relation to how capacity is assessed and making best interest decisions when patients are assessed as lacking mental capacity around treatment. Guidance around gaining children and young people was also provided. For example, the policy shared guidance on the types of consent, included both children and adults and was based on best practice guidance. The reference documents listed were the ‘Reference guide to consent for examination or treatment – Department of Health’, ‘GMC consent guidance (consent ethical guidance for doctors)’ and Standards for patient consent, particular to radiology – Royal College of Radiologists’. There was also a separate ‘Mental Capacity Assessment Guidance and Checklist’ document (dated 2017) observed whilst we were on site. It detailed core principles, record keeping and key roles, but was dated outside of the provider’s 5-year policy review schedule.

CCTV was observed to be in place in the reception area, and the installation of CCTV was mentioned within the risk register. The provider told us that information about the use of CCTV was displayed on an electronic notice board with rotating content in the main reception area, and that CCTV policy information was available on request. However, the inspection team did not observe clear and prominent signage at the point of entry informing patients and visitors that CCTV was in operation.