Trinity Medical Imaging

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

At our last inspection, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. There were issues with equipment, safeguarding and Infection protection control measures (IPC).

However, the service worked collaboratively with its NHS commissioners and NHS partners.

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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

During our inspection staff told the inspection team that there had not been any complaints or incidents within the last 12 months of our assessment. Information we received after the on-site visit confirmed there had not been complaints recorded within the last 12 months. However, staff said they would inform the registered manager (RM) or the lead technologist in the event of an incident or complaint. Staff were also able to outline what the service’s responsibilities would be in the event of an incident or a complaint, such as apologising to the patient and/ or their relatives on behalf of the service.

After our inspection, we were provided with information about 12 incidents that had occurred over the last 12 months. Incident reporting was completed via the services' information platform. Of the reported incidents provided, these were dated from January 2025 to September 2025, covering a range of issues. Each incident report included an after-incident action plan. Information showed the most recent 3 incidents, which occurred between August and September 2025, related to cancelled appointments. The after-incident action plans included informing the referring clinician, discussion at the provider’s performance meeting and rescheduling of the scan, where appropriate. However, staff we spoke to were not aware of these incidents, so wider learning was not shown.

There was a duty of candour policy (dated 2023), and staff showed understanding of their responsibilities to recognise and escalate issues. The policy was in date according to the providers 5 year policy review standards. It was aligned with NHS, national patient survey and CQC regulation. The provider’s duty of candour policy details what duty of candour this means, the types of events that constitute an incident, explains levels of harm, and how this information relates to the provider’s responsibilities in line with regulation. In this way the provider provided guidance and supported staff’s understanding of their responsibilities.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Referrals were received from private healthcare clinicians, patients self‑referring for ultrasound scans, and from the radiology department of an acute NHS trust that had commissioned services from the provider.

All referrals were screened by the service’s Registered Manager (RM) or by the lead Nuclear Medicine technologist under the direct supervision of the RM. The RM would then categorise the referral according to the appropriate pathway, for example, 'vetting' would facilitate referrals being categorised as urgent or routine. The RM would make contact with the referrer for further information if there was insufficient information provided.

Following referral, staff would contact the patient to agree on a suitable appointment date and time based on clinical need and the patient’s preferences. There was also a pending ‘provisional appointment’ system in place, where patients who had not yet been referred by their treating clinician but had contacted the service would have their details taken and could be offered a ‘provisional appointment’. Members of the inspection team observed this process, including this option being offered by the provider’s receptionist, who fully explained the process to patients. We saw patient’s pending information was managed within the service’s Electronic Patient Records (EPR) system. Staff advised that their EPR system incorporated the patient referral information, which generated alerts as to identified needs from the patient’s referral. The EPR system would be updated, and the patient would be contacted again to confirm the appointment once the referral had been received and reviewed by the RM. Patients would also be contacted and informed if their referral had not been received, and the patient advised to speak with their lead clinician. The provider’s EPR system was incompatible with other systems, such as those used within the NHS. However, the service did use appropriate radiology reporting systems to communicate and share their diagnostic scanning information with the patients’ referring clinicians. At the time of the visit, we were told that the service used the Radiology Information Systems (RIS) and was in the process of updating their systems to Picture Archiving and Communication Systems (PACS).

Urgent and cancer care referrals had a clinical standard of referral to appointment time within 10 days, routine referrals had a clinical standard of referral to appointment time within 4 weeks, and privately funded patients had a clinical standard of referral to appointment time within 2 days.

The service would communicate any issues or liaise with the patients’ treating clinician for case discussion.

There were monthly engagement meetings with the Medical Physics Expert (MPE) as a critical stakeholder. The Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) mandating the appointment of an MPE for legal, safety, and operational reasons. The provider also had systems in place to support the safe use of ionising radiation through engagement with an external Radiation Protection Advisor (RPA). The RPA acted as an independent specialist advisor and provided oversight, ensuring the service remained compliant with relevant legislation, including liaison with regulatory bodies such as the Health and Safety Executive. The provider and the RPA met on a monthly basis to review service performance, discuss regulatory updates, and address any identified risks. These regular meetings supported ongoing monitoring of radiation safety and ensured that safe systems of work were maintained and adapted in line with regulatory requirements.

This approach supported continuity and safe transitions within the service, including the implementation of updated procedures and guidance, helping to ensure patients remained protected from avoidable harm.

In the event of medical emergencies, staff on site would contact emergency services for assessment and suitable intervention such as emergency transfer to the most appropriate hospital. Some facilities were available and staff had the relevant training for emergency resuscitation until the arrival of emergency services. There were written policies and procedures in place to support this intervention.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

The Registered Manager (RM) was the safeguarding lead for this service. When we visited, some staff told us they would inform the RM if they had any safeguarding concerns regarding their patients, who would inform the referrers of issues found. However, some staff were not aware of the RM’s safeguarding lead role and told us they would instead inform another member of staff of safeguarding concerns.

There were no statutory notifications submitted or other evidence that safeguarding referrals had been made by the service in the 12 months preceding the assessment. The RM told us that the service considered it more appropriate to raise safeguarding concerns with the referring clinicians, rarely making direct safeguarding referrals themselves. The RM explained that patients were typically seen by the service for a limited period, whereas referring clinicians had an ongoing relationship and a more complete understanding of the patient’s needs and circumstances. However, the service had relevant safeguarding policies in place, which included contact details for their local authority safeguarding team and electronic facilities which allowed the recording of safeguarding referrals if any had been made. This meant that although systems were in place, standard practice did not adequately protect patients from potential harm.

The safeguarding children policy that was shared with the inspection team on the day of the visit had not been reviewed since May 2020 and the mental capacity assessment and checklist document had not been reviewed since May 2017. Which meant they were out of date according to the provider’s own 5 year-policy review schedule. After the visit we were provided with up-to-date policies including the ‘At Risk Adults Policy’, and the ‘Safeguarding Children policy’, both of which were within review expiry dates. Given this discrepancy, we could not be assured that staff had access to and were using the most up-to-date information and guidance available.

After the visit, the provider showed some evidence that the Nuclear Medicine (NM) technologists were all trained to level 3 for safeguarding adults and children, which was above the standards of training specified in the provider’s local safeguarding children’s policy. However, this conflicted with mandatory training records we reviewed onsite and some additional information provided after the visit, which showed training to level 2 in safeguarding children. The safeguarding training for the RM or the off-site radiologists was not shared for our review. The evidence did not assure us that training was aligned with 'Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff’, the intercollegiate guidance published by the Royal College of Paediatrics and Child Health (RCPCH). This nationally recognised best practice guidance recommends Level 3 safeguarding training for clinicians who work directly with children and young people (CYP), particularly where their roles involve assessing health needs and contributing to the evaluation of parenting capacity.

Overall, the service did not evidence that it had followed the correct processes to ensure that patients had been adequately protected from avoidable harm.

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

Where appropriate, staff were observed to support patient involvement and invite patients to express their preferences. For example, observation of clinical practice included a patient’s relative accommodated in the room during the patient’s scan. This was based on the patient’s preferences. Staff shared information about the associated radiation risks, including in pregnancy if applicable and confirmed that these risks were understood by both the patient and their relative. They recorded the patient’s written consent and their relative’s verbal consent. Although it was observed that a relative’s presence within the scanning room during a scan was not formally recorded in the patient’s care notes. Which meant the potential risks were not formally documented.

Where patients had consented, relatives were included in discussions as per the patients’ wishes. Staff support had been provided to explain procedures, answer questions and offer reassurance, as needed.

Staff were equipped to manage potential medical emergencies and issues with patient-related anxiety and aggression. The staff's mandatory training records showed that staff received training in resuscitation of children and adults, conflict resolution, and, when asked, could explain the appropriate use of their training.

Staff had completed relevant resuscitation training for babies and children and described the appropriate procedures for managing medically unwell adult patients. For example, staff we spoke to explained that they would report medical emergencies to emergency services and inform the Registered Manager (RM) according to local protocols.

Staff were able to describe how they would use de-escalation techniques learned through training to support patients experiencing distress or heightened anxiety. However, the provider had not ensured that staff had access to clear, service-specific policies and procedures relating to the management of medical emergencies involving children and young people, or the management of aggression within this patient group. This meant there was a potential risk that the specific needs of children and young people may not be consistently recognised or responded to appropriately.

Risk assessments related to the management of radiation-related risks were allocated to the Radiation Protection Supervisor (RPS), Radiation Protection Advisor (RPA) and Medical Physics Expert (MPE). As such, evidence of the service’s audits around dosage and administration of radiopharmaceuticals was submitted, for example, the annual CT dosage audit by the RPS, who was the RM. Other information shared also included audits related to the 6-monthly monitoring of personnel contamination by the RPS, monthly radioactive waste monitoring by the RPA and the annual audit reporting completed by both the RPA and MPE.

Pause and check processes were used and these were audited. The providers audit information supplied showed 100% compliance with the process.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Public-facing areas were located on the ground floor and included the main entrance, waiting area and reception. There were general toilet facilities and clinical areas, including scanning and control rooms and the hot lab.

A separate waiting room was available for patients to wait or change, including those arriving from hospital on trolleys or with an escort. Wheelchair access was available, including access to the hot lab and an accessible toilet within this area.

We observed that the location was clean, tidy and generally mobility accessible in many of the public facing areas. There was also signage that notified visitors that a hearing loop was available to support communication with those with auditory impairment.

The control area allowed appropriate visualisation of the patient during scans, and in-room audio facilities meant patients could be heard by staff in case the patient needed to communicate whilst staff were in the separate control room.

There were no separate access or dedicated clinic days for children and younger patients, nor were there dedicated areas to accommodate children and younger patients. However, we were shown large storage boxes of toys and games, which could be used with younger patients and we were told about facilities such as audio players within the scanning rooms, which could be used with children and young patients, when needed.

The main waiting area was spacious and could accommodate wheelchair access, the manual main entrance door and the reception desk were also wheelchair accessible. The seating consisted of wipeable chairs. There was a water dispenser with cups, and there was a selection of packaged biscuits at the reception desk. Within the waiting area, there was a digital display that rotated key patient information, such as restrictions advice for those who are pregnant or breastfeeding. There was a receptionist stationed at the reception desk to greet visitors, and CCTV was observed within the reception area, which provided staff oversight in public facing areas.

There was evidence of a clinical equipment service log. When we reviewed this, we found only 1 fault on the clinical equipment service log, regarding ultrasound. At the time of the inspection, ultrasound scans were no longer administered at this location.

We were also told about centrally managed equipment checks, via the service’s electronic system for equipment servicing schedules, appointment bookings, storage of patient information and ordering stock, including medical supplies. This system provided staff with prompts when weekly, monthly and less frequent staff equipment checks and maintenance were due.

During interviews with staff we were advised that the moving and handling equipment was not serviced in line with legal requirements for lifting equipment, covered by The Lifting Operations and Lifting Equipment Regulations (LOLER) 1998 or Health & Safety at Work Act 1974. During the visit, some electrical items had Portable Appliance Testing (PAT) labels that were out of date. For example, the Geiger counter, which was used for checking radiation levels, had a PAT label dated from 2018. This was of concern to the inspection team as the setting would be seen as a high-risk environment due to patient vulnerability and frequent equipment movement. Although PAT testing is not strictly required by law in the UK, maintaining electrical equipment safely is. Under the Electricity at Work Regulations 1989 and Health & Safety at Work Act 1974, the provider has a responsibility to ensure appliances are safe. Regular PAT testing is the preferred method to demonstrate compliance, along with regular visual inspections, which are a mandatory component of safe equipment maintenance. When issues were discussed with the RM, they acknowledged this was an issue, and we were told this would be addressed.

The service had an ‘Emergency Medications and Resuscitation Equipment’ policy; however, this did not reflect the equipment observed on site and did not provide assurance that systems were effectively implemented. The resuscitation equipment available did not align with the policy, and some items were out of date, including equipment that had expired in 2023. Other than what staff told us, there was no evidence available during the assessment that this equipment had been checked. In addition, a related policy ‘Patient Emergency Handling – Patient in Distress Desk Aid’, was last reviewed in 2018, which was outside the provider’s stated policy review cycle.

We were told the service was in the process of updating their website information, which would include referrers’ access to their referral criteria. The service had contacted the Administration of Radioactive Substances Advisory Committee (ARSAC), a committee of experts sponsored by the Department of Health and Social Care and were reportedly awaiting ARSAC guidance and advice to update their nuclear medicines procedures for patients and visitors of childbearing and breastfeeding potential.

The listed Radiation Protection Supervisor (RPS) was the Registered Manager (RM). The RPS is responsible for ensuring the service’s compliance with ‘local rules’, the legally required site-specific document outlining safety measures needed to protect staff, patients and the public from radiation. There was a list of ‘emergency contact details’ available at the reception desk, such as the Radiation Protection Advisor’s (RPA’s). With advice about reporting a ‘radioactive incident’ for staff on site.

TMI was a non-smoking environment, but patients and their visitors could smoke within designated outside areas. There was a fire safety policy, which covered fire safety procedures. There were annual fire drills, although none had been completed yet in 2026 and a weekly fire alarm check was reported by staff. There was clear fire safety signage observed, and clear fire evaluation plan information located at various parts of the location.

However, staff on site were unable to tell us about any designated fire marshals, which were included in the fire safety policy. Nor could they tell us about other fire safety compliance arrangements other than weekly testing of the fire alarm. We were able to review the fire safety risk assessment completed by the RM but the fire service risk audit was not submitted for our review.

In the event of an equipment or power outage emergency, staff told the inspection team that the contingency plan would be to cancel scheduled appointments as appropriate and to transfer patients who had already been injected to the local acute hospital. However, there are no formal agreements to support this.

Staff told the inspection team there was specific guidance related to management of COVID 19 and were able to provide details of the management protocols in place. We were provided with an infection control policy related specifically to covid 19 and guidance related to the management of infectious diseases was included in the risk register.

There was a Legionella management policy which was within the provider’s policy review date, appropriate to the service and aligned to the Health Safety and Executive guidance, ‘Legionnaires’ Disease. The control of Legionella bacteria in water systems. Approved Code of Practice and Guidance’.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

When we visited the service, we were told there were 2 members of clinical staff on site, which included the lead Nuclear Medicine (NM) technologist. There was also a receptionist. The radiologists and the Registered Manager (RM) worked remotely for most of the time. However, there was effective communication reported between on‑site and remote staff through the service’s messaging system.

We were advised that there was always a minimum of two NM technologists (i.e. two clinical staff) on site during the service’s operating hours. The staff and the RM told us that there were no formal or standardised staffing tools used to calculate safe staffing levels, as this was not required due to the relatively small size of the service.

Evidence submitted by the registered manager (RM) showed staff compliance rates with mandatory training for nuclear medicine (NM) technologists was 100%. We were told that reception staff did not receive radiation monitoring or radiation safety training, as they were only exposed to minimal levels of radiation.

We were not provided with the full mandatory training compliance figures for the RM and other radiologists. However, we were provided with recruitment policy evidence regarding appropriate recruitment checks in line with Schedule 3 of the HSCA 2008 (Regulated Activities) Regulations 2014, some training details, such as radiation protection training, and an associated policy on practising privileges to show appropriate practising requirements for the radiologists. The RM confirmed that consultant radiologists were provided with recommendation letters for revalidations.

The NM technologists we met with told us they had received their formal professional qualifications overseas and received competencies training with the registered manager as part of their role with this service. Many staff told us they had not worked with other services within the UK.

For the 5 employed staff, which included the RM, 3 NM technologists, and 1 receptionist, we saw that there was 0% sickness reported according to the annual sickness report dated March 2026. We were told there were no staff vacancies and no staff turnover since 2021.

Staff recruitment was managed by a director, who staff referred to as the ‘HR manager’. This person was non-clinical but was responsible for supporting the service to ensure the appropriate personal and professional checks were carried out, which included rights to work and identification checks in line with Schedule 3 of the HSCA 2008 (Regulated Activities) Regulations 2014. Recruitment was based on shortlisting. The HR manager and the RM interviewed all job applicants, to ensure applicants were suitable for the roles. There was also a local induction programme and probationary period for all new staff. The RM told us that posts were advertised both in the UK and outside of the UK. However, owing to national shortages in NM staff, the employed NM technicians were sponsored to work in the UK by the service.

The existing complement of staff was able to support absence cover in the event of staff leave and sickness. The RM explained that they approved staff leave, thus could ensure there was sufficient staff cover and could adjust patient lists if needed, given the pre-booked appointments system in operation.

We observed and were told about the good working relationships within the staff team. The provider’s staff team meeting minutes we were provided with did not highlight any recorded issues or concerns about the ability of staff to work together to deliver appropriate care to their patients.

Patients and their relatives that we spoke to did not raise any concerns regarding their experiences of the staff team’s ability to work together, to deliver a good standard of care.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed that the location was visibly clean, with an acceptable standard of general hygiene. This included both the public-facing areas, such as the waiting area, reception and toilet facilities but also the staff areas such as the kitchen and first floor facilities, that we observed. There were also good supplies of hand sanitisers, PPE and clinical cleaning materials, such as cleansing wipes available throughout the location.

The ‘Infection Control’ policy was last reviewed in June 2020, which was outside of the provider’s own 5-year policy review schedule. We found staff were not consistently ‘bare below the elbows’ in line with recognised infection prevention and control (IPC) standards and guidance, such as the National Infection Prevention and Control Manual (NIPCM) – England.

Staff did not consistently use the provider’s clinical cleaning checklists, and there was no clear alternative system in place to show when reusable equipment had been cleaned and was safe for use. This was not aligned with national IPC guidance or cleanliness standards. We did not receive cleaning records for reusable games and toys used by children and young people, which meant the provider could not demonstrate that these items were regularly cleaned for use.

The provider shared evidence that Nuclear Medicine technologists and reception staff completed daily cleaning records, which were reviewed weekly by the Registered Manager. Records from contracted cleaning staff and audit data indicated full compliance with cleaning schedules. However, this was not consistent with what we observed. It was not clear how the provider assured themselves that the reported compliance was accurate, as clinical cleaning checklists were not being completed in real time or used routinely in practice we observed.

Both general and clinical waste were observed to be well managed, including the appropriate segregation of waste and signage to support these processes. We were told about contracts for the disposal of clinical waste and did not observe issues with the appropriate storage and waste management arrangements when on site.

Patients we spoke with did not express any concerns regarding the standards of hygiene maintained within the service.

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

We observed that medications and radiopharmaceuticals were appropriately stored and disposed of in line with the local medication storage policy, which aligned to national guidance on the storage of medications. Where disposal of medications was required, arrangements were in place where these were returned to the supplying acute NHS trust.

There were relevant medications policy, ‘drug storage protocol’ and policy around the administration of emergency medications, that were both within policy review expiry dates. The service had formal local arrangements where the radioactive tracers used were supplied by a local NHS trust. The RM then ordered and prescribed medications, used for patients, in line with referral information, from a local NHS trust, with whom the service held a formal arrangement for this provision. In this way, Patient Group Direction (PGD) was not required due to the arrangements already in place.

Emergency medications were located on the ‘emergency cardiac arrest trolley’ according to the service’s ‘Administration of emergency medicals and resuscitation equipment policy. However, the ‘emergency cardiac arrest trolley’ was not observed and staff did not show this to the inspection team during the on-site visit. Instead, the inspection team were shown a resuscitation kit bag located at the reception desk and we were informed that the oxygen cylinder and anaphylaxis kit were stored in the ‘hot lab’. Thus, the emergency medications and resuscitation equipment were held in separate areas. This arrangement had the potential to delay the provision of emergency support to patients or visitors in the event of clinical deterioration, although the risk was partly mitigated by the small size and layout of the service.

The service used two tracers - Iodine and technetium. There were formal arrangements with local NHS providers around the attainment of the services radiopharmaceutical this included the secure transportation and systems in place to ensure daily staff checks at the time of delivery.

During our visit we found evidence of medication that was past its expiry date. However once informed about this, staff took appropriate action to remove it. There was a recorded incident where the provider took receipt of an incorrect delivery of radiopharmaceuticals which led to insufficient stocks available for planned patient appointment. The stock issue was addressed by the RM and the patient appointments were re-booked. Medication management was undertaken in line with the treatment plan and referral information provided by the referring clinicians, which is consistent with the service’s role and remit.

Although the staff we spoke with during our visit could not identify specific medication audits or incidents related to medications, they could tell us about their role in receiving delivery of medications, how deliveries were checked and then logged onto the services electronic systems to record stock. They also shared details on how they could report any supply issues to the RM via various systems available, such as phone calls, emails and via the staff teams internal messaging system. Staff also told us about the RM’s role in managing the restocking of medications and other clinical stock, which also included use of the service’s electronic systems. Evidence of recent IRMER compliance related audits was not submitted for this inspection.