Mount Gould Hospital

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected. We also looked at systems and processes which kept people safe from harm.

This key question has been rated good. This meant people were safe and protected from avoidable harm.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

People we spoke with during the assessment of the service did not have any safety concerns.

The diagnostic imaging service at Mount Gould Hospital formed part of University Hospital Plymouth trust's community diagnostic imaging service. Systems and processes were managed centrally at the trust's main Derriford hospital site. The service had processes to report and investigate incidents. Learning from incidents was shared across all trust locations. Incidents were discussed at governance meetings. There were up-to-date policies and procedures to support incident investigation and duty of candour (being open and honest with people when things went wrong). Staff understood the types of incidents that needed to be reported and the importance of duty of candour. In the 12 months prior to the assessment of the service there had been no serious incidents, or incidents relating to radiation that required reporting under Ionising Radiation (Medical Exposure) Regulations.

Leaders told us they encouraged staff to report all incidents to ensure risks could be identified and action taken. Staff told us they felt the service was responsive to concerns and processes enabled information to be share with everyone in a timely way.

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

Feedback collected by the service showed over 95% of people that had used the service said staff explained how they would receive their X-ray results. This also showed 94% of people felt they received adequate information about their X-ray.

The service accepted referrals from GPs, outpatients, or inpatients at Mount Gould Hospital. Inpatient appointments were prioritised due to clinical need. Radiographers vetted referrals appropriately to justify an X-ray was necessary. Where referrals were not justified, the referrer was contacted or externally based radiologists reviewed the referral. Outpatient and GP referrals were prioritised and appointments booked based on the urgency of the referral. The trust’s centralised booking team coordinated the booking of appointments using booking policies and exclusion criteria. However, guidance was not always consistent because department operating procedures indicated no patients under 18 years old could be seen at the service, but booking guidance indicated all ages except children under 2 years could be seen at the service. Staff were required to follow local rules to ensure X-ray images could be taken safely. Staff were required to demonstrate they were competent to work at the service. The service did not report findings on X-ray. Images were reported on by an external third-party service or at the provider’s other location, Derriford Hospital. There were appropriate systems to escalate unexpected findings on an X-ray image.

Staff told us the process of booking appointments worked well, and they were able to communicate with the booking team effectively.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People using the service told us they felt safe and supported.

Staff received suitable training in safeguarding adults and children. Refresher training was required, and the service monitored compliance with 90% of staff completing safeguarding adults training and 95% completing safeguarding children training. Staff could identify signs of abuse and understood how to raise concerns. They could describe what action to take to protect people at risk of or suffering harm. Staff understood the Mental Capacity Act and Deprivation of Liberty Safeguards and had completed mandatory training on these. There had been no safeguarding referrals made in the 12 months prior to the assessment.

The service had up-to-date policies and processes to protect adults and children from abuse and unsafe treatment. Safeguarding information was available onsite and staff knew how to access online policies, procedures and advice.

Staff told us the training they received helped them to identify safeguarding concerns and gave them confidence to raise concerns if they were to identify abuse.

The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe and supportive.

Where service provision was affected at one location, action was taken to provide suitable alternatives for people. There were appropriate processes to respond to a medical emergency. Staff received training in basic life support and were supported by a third-party healthcare provider to provide care for people. The service carried out safety checks including checks to assess a person’s pregnancy status in line with regulation.

During the assessment we observed staff following safety protocols.

Staff told us they were always able to contact the radiation protection supervisor and the medical physic advisors to find radiation protection guidance when needed. The medical physics team told us the service responded in a timely way.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

During the assessment of the service, we saw equipment being used safely for its intended purpose. The service had suitable signage to warn people where ionising radiation was being used. Doors to the X-ray room were lockable to prevent unauthorised access and the room was designed to protect staff from over exposure of radiation. Staff wore radiation dose badges which were monitored by the service to identify over exposure risks. Lead aprons were available, and checks completed to ensure they were safe to use. Records showed servicing of X-ray equipment was performed by a third-party company. The service safely stored chemicals or substances hazardous to health. Safety checks on portable electrical appliances had been completed. The waiting area had information posters explaining the risks of receiving X-rays. This included information about risks for people who were pregnant. Fire exit routes were kept clear and extinguishers stored safely.

The service was registered with the Health and Safety Executive (HSE) to use ionising radiation. They had systems and processes to protect people from ionising radiation. Staff performed quality assurance checks on X-ray equipment to ensure it was safe to use. There was a system to report and repair faults. Staff understood the importance of reporting faults in a timely way.

Staff understood what to do in the event of an emergency and described their responsibilities in case of fire. They told us faults to equipment were repaired quickly.

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

People using the service told us staff were knowledgeable. One person said, “staff were quick, skilful, and efficient. I had no complaints whatsoever”.

The service was staffed by qualified radiographers. There were processes to ensure radiographers employed were registered with the Health and Care Professions Council (HCPC). Records showed the service carried out all required staff recruitment checks, including enhanced disclosure and barring checks. The service had up-to-date policies to recruit and manage staff performance. Staff received an induction to the service and mandatory training to support them to perform their roles. Mandatory training included training in autism and learning disabilities. The service had processes to monitor mandatory training refresher due dates and had plans for staff to complete expired training. Staff received annual work appraisals.

Staff told us appraisals covered work performance, career progression and development opportunities. They felt appraisals helped them perform their roles. Staff also received regular supervision support from senior staff. Staff told us, “We have access to really good continued professional development opportunities”.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading.

Feedback collected by the service showed over 99% of people using the service found the department to be clean or very clean. People using the service told us the location was clean and tidy. One person commented, “it was absolutely clean, tidy and all was accessible, while another said, “everything was spotless there”.

During the assessment of the service, we saw the environment was visibly clean and tidy. Fixtures, fitting and foam pad (used to support a patient when receiving an X-ray) were free from damage and easily cleaned. Hand washing facilities were available in the clinical area. Staff were ‘bare below the elbow’ in line with guidance. We saw staff following hand hygiene procedures and completed appropriate cleaning between appointments. Personal protective equipment (PPE) was available in sufficient quantities. Clinical waste was appropriately disposed of and stored safely.

There were processes to regularly clean the environment and equipment. Staff received training in infection prevention control. The service had up-to-date policies to prevent the spread of infections. The booking process identified people with infections which allowed staff to offer appropriate appointments.

Staff told us they would see people with infections at the end of the day to reduce risk of spreading infections. They felt they had enough time to perform cleaning between appointments. They knew who to contact to find more advice on infection prevention control.

The service did not administer medicines or contrast (injected substance used to enhance the visibility of internal structures).