Trinity Medical Imaging

On this page

• 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

At our previous assessment, this key question was rated Good. At this assessment, the rating has changed to Requires Improvement.
This indicates that leadership and management were not consistently effective. Leaders did not always create a culture that supported learning, improvement, and the delivery of high-quality care

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff of all levels described an open culture where they felt able to express their views. We were told that, given the size of the service, there were no staff surveys, but staff could feedback at staff meetings and face-to-face discussions with service leaders.

Staff who were patient-focused and patients we spoke with confirmed this. For example, during observations of the staff interactions with patients and the relative’s staff were informative, answered questions and accommodated patients’ preferences.

The provider’s mission statement shared details of the service’s core values, which included values associated with exceeding their patients’ expectations, maintaining high standards and treating patients with courtesy, kindness, respect and dignity. We observed staff adhering to the provider’s mission statement. The patients and relatives we spoke with agreed that the values in this mission statement had been met.

The provider’s patient charter specified that the service would contact their patients within 1 working day of referral to arrange appointments, perform cancer care imaging within one week and routine imaging within four weeks, offering an explanation when these are not met. Aiming to see 80% of their patients within 20 minutes of their appointment time. When we visited, we confirmed that paper-based patient surveys were available and staff told us how patients could report their feedback, online or for those who required it, via the paper-based patient survey, which staff would facilitate as needed. The providers’ performance indicators show that they were meeting the standards specified for cancer care patients and routine patients from figures between June 2025 and February 2026. However, the inspection team were informed that patient waiting times were not monitored by the service. This meant the provider could not demonstrate or provide assurance that waiting time standards were consistently being met.

Staff did not show knowledge of the risk register and the items on it. Although they were aware of infection control measures for the management of covid 19 and could apply these, they would not be aware of the provider’s risk management guidance for other infectious diseases, including emergency or urgent situations, particularly when the RM was off-site or not immediately available. However, the RM told us that remote radiologists would be available through a 'reporting rota' to maintain reporting services and clinical oversight in their absence.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Directors had clear roles and responsibilities. The registered manager (RM) was also the medical director, a registered radiologist, the safeguarding lead, the listed Radiation Protection supervisor (RPS) for the site and sat on the provider’s executive board. We were told the RM was present at the service once a week and supported the NHS commissioners’ meetings, Radiation Protection Advisor (RPS) meetings and Medical Physics Expert (MPE) meetings. We were told the RM was available on the service communication system or telephone when not on site. The RM was responsible for the screening of referrals received, reviewing incidents and complaints. They also completed appraisals, sat on interview panels and oversaw staff competencies. The ‘HR manager’ (director) was responsible for staff recruitment, financial and contract management. They were at the service on an ad hoc basis, often daily, but were not available when we visited.

Appraisal compliance for the 3 employed nuclear medicine (NM) technologists employed was 100%. Due to the small size of the service, there were limited opportunities for career progression on site. However, staff told us they had opportunities to develop leadership skills by taking on additional responsibilities.

For example, the lead NM technologist was being supported to develop their role, including contributing to staff appraisals and vetting referrals. They also helped oversee the day-to-day running of the service and acted as a point of contact for staff in the absence of the registered manager. Clinical staff were also supported to develop specialist skills, including leading projects such as the development of new processes and the set-up of the DEXA scanning service.

However, leaders were not always aware of or responding to risks within the service. During the inspection, we identified concerns including out-of-date policies, expired portable appliance testing (PAT), out-of-date resuscitation equipment, and safeguarding referral processes that required improvement. This indicated that governance and oversight arrangements were not consistently effective.

People did not always feel they could speak up and that their voice would be heard.

Staff described an open culture and told us they felt able to raise concerns with the lead nuclear medicine (NM) technologist or the Registered Manager (RM). The lead NM technologist was based on site daily and oversaw the day-to-day running of the service. Staff said they could also contact the RM through the service’s communication systems.

However, staff were not aware of a specific Freedom to Speak Up (FTSU) policy because there was no specific FTSU policy in place. While they could explain how they would escalate concerns, this was mainly through local line management rather than a formal FTSU process.

Leaders told us staff surveys were not carried out due to the small size of the team and close working relationships. While this was seen as a positive by leaders, some staff commented that the close-knit nature of the team could make it difficult to give honest or constructive feedback. Although this had been referred to in appraisal discussions, it was not clear how these concerns were formally addressed.

The RM was identified as the FTSU guardian. They told us staff were encouraged to report concerns and incidents, and we saw evidence of incidents being recorded and followed up. However, we did not see clear evidence that risks or concerns were routinely discussed in team meeting records, which limited assurance that learning was consistently shared.

Patients and relatives told us they felt able to raise concerns if needed. There was limited visible signage about complaints processes or external organisations, such as the Patient Advice and Liaison Service (PALS) or the Independent Sector Complaints Adjudication Service (ISCAS). However, information about how to complain was available on the provider’s website, a complaints leaflet was available and we were told that information about complaints was displayed on the electronic notice board with rotating content, located in the main reception area.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders supported equality, diversity and inclusion in some areas. Staff told us reasonable adjustments, including flexible working arrangements for caring responsibilities, were available.

Equality, diversity and inclusion training formed part of the mandatory training programme, and clinical staff compliance was 100%.

However, there were limited arrangements for wider recruitment or monitoring of EDI due to the size of the service. Workforce data showed all staff were from an Asian or Asian British background. While this reflected some of the local population, it did not represent the full diversity of the communities served.

We were told there was engagement with a local NHS trust by providing clinical placements for radiography students and there was evidence of poster presentations. The provider was unable to undertake or participate in research due to its current Administration of Radioactive Substances Advisory Committee (ARSAC) licensing restrictions. Opportunities for broader engagement, learning and collaboration on EDI were limited. Although staff were encouraged to attend external events such as the British Nuclear Medicine Society meetings, this was not supported by a structured approach to developing inclusive practice.

Overall, while some positive arrangements were in place, leaders had not fully developed a proactive and structured approach to promoting equality, diversity and inclusion across the workforce.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders had defined roles and responsibilities, including those of the Registered Manager (RM) and lead Nuclear Medicine (NM) technologist and most staff understood these. However, these roles were not consistently effective in practice. Governance systems were not operating as intended, and leaders did not have adequate oversight of the quality and safety of the service.

Systems to monitor, assess and improve the service were not robust or consistently applied. During the inspection, we identified multiple concerns, including infection prevention and control practices that did not always follow local policy or best practice, and safeguarding processes that did not provide assurance that people were protected from avoidable harm. Systems to check and maintain equipment were also not consistently implemented. Multiple policies were outside of the provider's own 5 year policy review schedule.

The service had a flat governance structure, with the RM responsible for a wide range of key functions, including referral screening, incident investigations, policy review, safeguarding, and external meetings. Although the RM told us that remote radiologists would provide cover in their absence, through a rota system for reporting to ensure continuity of reporting services and clinical oversight. Staff were unable to clearly describe who would take responsibility for the RM’s duties when they were not on site. While staff told us they could contact remote radiologists for clinical advice, this did not provide sufficient assurance of consistent leadership and oversight.

Patient feedback was collected through surveys and online reviews. However, staff were unable to demonstrate how this feedback was used to improve the service.

The provider had a risk management policy, but this had not been reviewed since 2018 and was outside of the provider’s review cycle. Although the RM could describe risks, staff were not familiar with the risk register or its contents, which was not in line with the provider’s policy.

The service maintained a risk register; however, it did not reflect all relevant risks. Issues identified during the inspection, such as out-of-date equipment, gaps in portable appliance testing (PAT), and outdated policies, were not included. While risks had action plans, completed risks were not consistently closed and some remained on the register for several years, including entries dating back to 2017. This meant the register did not provide an accurate or current overview of risks.

Staff understanding of risk management processes was limited. While they were aware of some infection control measures, they did not demonstrate a wider understanding of how risks were identified, managed and escalated, particularly in the absence of the RM.

Although staff told us they felt able to raise concerns, there was limited evidence to support this. Staff we spoke with did not describe recent incidents and referred us to the RM for further information. However, the provider later shared records showing multiple incidents had occurred in the previous 12 months and we were told incident reporting was completed via the services’ information platform. This indicated that incident awareness and feedback systems were not working effectively in practice.

We found ongoing gaps in how procedures were implemented, monitored and assured. This was more evident when leaders were not on site. There was inconsistent compliance with service protocols, best practice and national guidance, including infection prevention and control standards, reusable equipment cleaning processes and equipment maintenance.

Not all procedures and quality assurance systems were fit for purpose. Some policies were outdated, incomplete or not specific to the service. For example, guidance for patients of childbearing or breastfeeding potential was not sufficiently detailed. Referral criteria were not consistently accessible to all referrers. These issues had been identified at a previous IR(ME)R inspection in September 2025 but had not been addressed.

The service relied heavily on one senior clinician to provide clinical leadership and governance oversight. While other staff had appropriate skills, there were no clear or formal arrangements to ensure continuity in all these responsibilities in their absence. This created a significant risk to the safe running of the service and meant there was limited assurance that effective oversight would be maintained. This concern had also been identified previously and had not been resolved.

Overall, governance systems were ineffective. Leaders did not have clear or up-to-date oversight of risks, and systems were not sufficient to ensure safe, consistent and sustainable service delivery.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders had developed some working relationships with external partners, including commissioners, and held monthly meetings to discuss performance, targets and action plans. This demonstrated a regular approach to partnership working and oversight of service delivery.

The service collected patient feedback through surveys and online reviews. This showed the service was able to meet the needs of people who used it in some areas. However, there was limited evidence of how feedback was analysed or used to drive improvement.

The provider did not carry out formal staff surveys. Staff could share views through meetings and daily contact with leaders. While staff felt able to raise concerns informally, the service lacked structured and proactive approaches to capturing and responding to staff feedback.

Opportunities for patients, relatives and the wider community to engage with the service were limited, with no clear routes to influence senior leaders or commissioners.

Patients and their relatives or carers were able to speak with staff on the phone or face to face on their arrival at the service. Leaders had not fully considered how to adapt engagement approaches for people at risk of digital exclusion. This limited assurance that all people could access information, share their views, or contribute to shaping the service.

Overall, while some partnership working and feedback mechanisms were in place, engagement with staff, patients, and the community was not structured or effective to drive sustained improvement.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff had some opportunities to contribute to service development. For example, leaders told us about innovations such as contrast CT for parathyroid scanning, and clinical staff taking a lead role in developing protocols.

Staff said they were encouraged to attend professional events, such as the twice-yearly British Nuclear Medicine Society (BNMS) meetings, and to contribute to poster presentations. There was engagement with a local NHS trust by providing clinical placements for radiography students. We did not see evidence of active participation external audit, awards or recognised accreditation schemes. The provider was unable to undertake or participate in research due to its current Administration of Radioactive Substances Advisory Committee licensing restrictions. The 2025 Medical Physics Expert (MPE) audit report confirmed the service did not undertake research and operated largely as a standalone service.

The service had a sustainability policy (2024), which outlined aims to deliver environmentally responsible care. This included digital and paper-light systems, such as electronic referrals, reporting, and patient communication, alongside energy-saving measures like sensor lighting, timed heating and equipment shut-down processes. The service also aimed to reduce unnecessary imaging and improve efficiency through effective scheduling.

While these approaches were in place, it was not clear how sustainability performance was monitored or shared with staff. Meeting records did not show evidence of discussion or review of sustainability targets or progress. In addition, staff training programmes and appraisals did not include sustainability as part of learning and development.

Patients were able to provide feedback through online and paper-free options, and information was shared via digital and printed materials. However, there was limited evidence to demonstrate how feedback, learning or innovation activities were consistently used to improve outcomes or drive measurable change.

Overall, while the service demonstrated some examples of innovation and good practice, systems to support learning, improvement and continuous development were not fully embedded or consistently applied.