Good Hope 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

This means we looked for evidence that people were protected from abuse and avoidable harm. This is not the first assessment for this service but is the first time the service has been rated. This key question has been rated good. This meant people were safe and protected from avoidable harm.

There was a positive and proactive culture around safety, patients were protected from the risk of bullying, harassment, abuse, discrimination and avoidable harm and neglect. Staffing levels ensured the service met the needs of people; staff understood risk factors and these were assessed in line with policy. Medicines were managed in a safe way which met people’s needs. However, some people were not always protected from the risk of infection, and the environment and equipment did not always support the safest of care for people . There were issues with the safety of some emergency trolleys and storage of chemicals.

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. Lessons were learnt to continually identify and embed good practice.

Safety of patients and staff was a priority. Staff were aware of the risks some of the equipment used posed to themselves and others. They focused on the process and the equipment being used safely for everyone. Staff reported most incidents in relation to equipment failures and other safety concerns should they arise. However, staff told us they did not always have the time to report all incidents of missed findings. Staff believed the more serious cases of missed findings were reported using the incident reporting system. However, there was no assurance this was the case due to there being no awareness of what was going unreported. We raised this concern with the leadership team at the end of the inspection.

Incidents reports were mostly either low or no harm. Data from the service showed there were 54 incidents reported by the service between October 2025 and April 2026. The majority of these incidents were graded low harm (27 incidents) and no harm (25 incidents). Imaging/radiology all areas had the most incidents (24 incidents) followed by CT scanning (18 incidents). The most common incident reported by the service was extravasation of contrast or intravenous infusion.

There were very low numbers of serious incidents and no external safety incident reports. There was 1 serious incident reported in CT scanning which related to a delay in diagnosis for a patient. No never events had been reported by the service between October 2025 and April 2026. There were no incidents reported under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) or to the Health and Safety Executive (HSE) between October 2025 and April 2026.

There was a culture of learning when things went wrong. Staff were encouraged to raise concerns and felt they would be treated fairly if they spoke up. Staff said they were confident to report incidents and knew what events or concerns had to be reported and received feedback from incidents raised. These included incidents considered as a ‘near miss’. Staff said they were involved in any investigations which might be needed should an incident occur and described learning from certain issues which had arisen. They also said they would report concerns about potential risks proactively so they could be managed before any safety event happened.

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.

Safety and continuity of care was mostly a priority with a collaborative approach. However, some staff reported times when patients were brought to the department by portering staff. The patient might then be left without someone from the ward, such as a healthcare assistant, to handover the patient or explain any key risks. Staff in the imaging department said this sometimes increased safety risks for the patient, other patients, and the staff if there were health or safety concerns the imaging staff were not made aware of. Imaging staff said the policy guidance for those patients who needed extra support were not always met if they were unaccompanied by ward staff or someone who could speak for them. However, during our inspection of the main imaging department, those patients who needed to be accompanied by a member of the healthcare team did have someone present with them.

Policies and processes about safety were aligned with other key partners who were involved in people’s care. The service had a Cauda Equina Service which operated 7 days a week, 8am until 7.30pm. Cauda Equina is considered to be a spinal emergency where the nerves in the spinal canal become suddenly compressed. Outside of the service’s routine operating times, patients were triaged for Cauda Equina and anyone who was identified as a red flag were transferred by emergency transport to another of the trust’s hospitals where specialists were based. The service only had 1 static MRI scanner available at the time of the inspection which was why the pathway was implemented.

Staff were vigilant to ensure they had the correct patient and correct procedure being carried out. Staff checked verbally with the patient their name, address and date of birth. They then matched this with the wristband if the patient was an inpatient of the hospital and checked it matched with the computer record for the patient. If the patient was not able to confirm their personal details, the staff checked the wristband or asked for confirmation from the clinical staff who were accompanying the patient to confirm the identity alongside the patient record. They also checked with any family members who were with the patient.

Any children who attended the department had to be thoroughly ‘vetted’ before any procedures. Vetting is a triaging process where all patients are reviewed by a radiologist or radiographer to make sure the procedure is clinically appropriate, safe and can be justified. Any young child having an MRI or CT scan would be accompanied by a nurse and doctor.

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. The service shared concerns quickly and appropriately.

Staff were confident about recognising abuse or neglect, or the risk thereof, and confident in how to raise an alert to specially trained staff in the hospital. Some staff had raised a concern in the past and remarked on how they were reassured by the specialist staff they had taken the right steps. One member of staff said they felt the safeguarding team were supportive and they felt able to raise any concerns with them even if it was potentially not a safeguarding issue.

Staff were trained in all matters relating to safeguarding and this was updated as required to make sure their knowledge was up to date. Staff said the training equipped them to be able to act when something concerned them, and they were aware of how to report an issue and who to contact. Information provided showed the service had met the trust target of 90% for safeguarding level 3 training in both adults and children with compliance of 94.6%.

There were no specific children’s waiting areas within the whole of the imaging department. Staff told us the number of children who used the department was low and therefore it was not feasible to dedicate an area for children to wait. To reduce any potential safeguarding risk, staff ensured there was a suitable adult with the child at all times. In addition to this, staff were able to see alerts for children who may have known safeguarding concerns so staff would be more vigilant and provide stricter oversight of children waiting.

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. However, some basic training in life support was not meeting the trust target by around 20%.

People were informed about risks and how to keep themselves safe. Patients who were receiving a scan were informed about risks and how they were mitigated: such as minimising the length of time of a scan and limiting exposure to radiation, magnetism, or radio waves. Staff explained to patients about the need to be very still to make the images as clear as possible. If a patient could not maintain the required stillness, the scan would be aborted if it was taking longer than the permitted safe time or that was a risk. Patients were able to be lightly sedated by the doctor looking after their care if this helped the scan to be delivered safely.

Staff asked people if there was anything they were worried about and were able to manage this in a positive way to help them feel less anxious. Staff explained how the imaging process was almost entirely non-invasive and pain free. Patients who were in pain could be returned to the ward to receive pain medication if this would help the process be safer and more effective.

Staff explained to the patient about the need to balance the risk from any procedure and take a proportionate approach to their health to help them get better. In addition to this, staff ensured patients received the right procedure at the right time. We observed radiographers reviewing patient history prior to undertaking a plain film X-ray to reduce any risk from unnecessary exposure. Additionally, staff reviewed the referral request to ensure the modality selected was the most appropriate for the health concerns raised. If staff had any concerns about the referral, staff would contact the referrer to discuss.

Staff completed risk assessments for all patients requiring imaging. All patients in the childbearing age-range were assessed for the risk relating to pregnancy. However, we found during our inspection, the age for when staff started to ask patients this question varied in different areas. We found some staff asked patients when they were 11 years old, some asked when they were 12 and other areas when the patient was 10 years old. We raised this with the leadership for the service who confirmed they follow Ionising Radiation (Medical Exposure) Regulations which is 11 years old to 55 years old. In addition to reviewing the pregnancy risk for patients undergoing imaging, staff also assessed patients for the risk of reduced kidney function (when patients were undergoing investigations with contrast) and anaphylaxis risk.

We observed staff using the Society of Radiographers “pause and check” system with posters displayed in some areas as well. Pause and check refers to the reminder for staff to confirm the patient and investigation are correct by using a set of prompts. When staff called patients in for their appointment, they always checked to ensure it was the right patient by asking them to confirm their identity. Staff completed audits of the pause and check system within CT scanning. The most recent audits completed were between June and September 2025. Compliance against the pause and check ranged from 43% in June 2025 to 75% in August 2025. Audit results for September 2025 showed there had been a decrease in compliance to 48%. The most common element which staff failed to check during this time was the patient’s cannula site. Audit results were communicated with staff to enable improvements to be made.

The service had support from radiation supervisors, radiation protection advisors and medical physics experts in line with Ionising Radiation Regulations 2017. Staff told us they could contact them quickly and easily when required. In addition to the right technical support staff, there were also ‘local rules’ which staff followed to ensure they were not placing themselves or patients at risk from ionising radiation. Local rules are legally-required, mandatory site-specific safety procedures which describe how staff must manage, monitor and restrict exposure to ionising radiation.

The service audited the lead coats to ensure they were appropriately maintained and safe for staff to use, which was in line with the Ionising Radiations Regulations 2017. Lead coats are protective items of equipment staff used to protect from exposure to X-rays. The most recent annual audit was completed in March 2026 and found all items passed the requirements.

The service completed Local Safety Standards for Invasive Procedures (most commonly referred to as LocSSIPs) audits in interventional radiology and mammography. Between January and March 2026, interventional radiology achieved 99% compliance with the expected safety processes when patients underwent the procedure and mammography achieved 78% compliance. Areas for improvement were identified and discussed and further auditing planned.

Staff received clinical life support training to enable them to manage a deteriorating patient. Compliance with training was recorded as 71.9% which is below the trust target. Despite the low compliance rate for this training, staff we spoke with were confident in what actions to take in the event of a deteriorating patient.

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

Facilities, equipment and technology were mostly well-maintained and supported staff to deliver safe and effective care. Most of the equipment was used 24 hours a day, 7 days a week, and supported planned and unplanned care at the hospital. However, one of the X-ray machines had developed a fault which meant one of the arms used to lower the machine towards the patient did not have the required resistance. This had been noted by staff, and the faulty button had been taped over, and staff therefore used the button on the other arm to lower the machine. The second arm worked safely when we tested it. However, the use of sticky tape did make the button less operative, but it fell short of infection, prevention and control guidance as it was sticky in places where it was breaking down. Staff told us there had been 1 near miss incident reported in May 2025. Staff had ensured this was on the department’s risk register and there were plans to replace the equipment this year.

Staff raised concerns over some areas within the department in relation to estates’ concerns. Within CT scanning room 2, there were ceiling tiles which had cracked around the ventilation system. Staff told us it was difficult to address the estates’ issues due to the demand on the service, as this would require the equipment to be out of use. However, there had been no cancellation of CT scanning lists within the last 6 months due to problems with the infrastructure. Staff hoped when the new CT scanning machine arrived in the emergency department, it would enable the area to have essential estate works completed.

Staff were aware of the risks any of the equipment being used posed to them or to people using the service, or those accompanying them. Staff were respectful of the rules around the use of radiation and made sure they were standing in the safe area when using equipment. This was generally either behind a safety screen, or in the case of computed tomography (CT) and magnetic resonance imaging (MRI), in a separate room. The doors to the scanning room were either locked to prevent anyone unauthorised or accidentally entering them when the equipment was in use, or the area was locked with access only for staff with permission to enter.

The computers used to review images and input information about the patient were all working as required. Staff said any issues with the equipment would usually be attended to quickly by maintenance staff and none could remember long periods of time without functioning key equipment. However, some staff raised there were still issues around not having enough computers to enable them to complete their roles.

The process was effective for ensuring emergency equipment, including the resuscitation trolleys and anaphylaxis kits, were well maintained and ready to use. We found resuscitation trolleys had tamperproof mechanisms and were checked daily with all checks being passed.

Some items in other clinical trolleys were out of date, and checks were not always being carried out. We reviewed a selection of clinical consumable items across the department including cannulas, dressings, airways, suction tubing, syringes, biopsy kits and blood sample bottles. A trolley in the interventional radiology department had 24 items which were out of date. We raised this immediately with senior staff in the department. However, we were told staff found it difficult to find the time to check the trolleys. In addition to this was another trolley at the side which had a further 3 out of date items. Staff told us this trolley was for training purposes. However, there was no sign to identify this and there was a risk that not all staff would be aware and potentially use out of date items. We raised this with the lead of the department who immediately removed all out-of-date items from the trolleys. We also reviewed 6 items of equipment and found their portable electrical testing and services had been completed.

Staff did not always reduce the risk to patients from correctly managing items which were under the Control of Substances Hazardous to Health regulations. We found 2 separate incidents relating to the incorrect storage of chlorine tablets and solution. We found chlorine tablets in an unlocked cupboard in the ultrasound department. We also found a bottle of chlorine solution in an unlocked cupboard in the CT preparation area. This solution had been prepared 5 days prior to finding it which would also indicate this would no longer be appropriate for use. In both situations, we shared this with staff working in the area for this to be safely resolved.

Staff disposed of clinical waste safely. The management and disposal of sharps and waste was completed in accordance with the trust policy. We observed staff correctly segregating clinical and domestic waste. Waste bins were enclosed and foot operated. Sharps bins were correctly assembled and below the fill line. Staff in nuclear radiology followed strict processes for the management of waste in this area.

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.

There were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care which met their needs. The service had minimal vacancies across all modalities and job roles. Most of the job roles within the service were at planned levels or slightly above. The exceptions to this were in administration and clerical staff who supported the service (4.85 whole time equivalents below the establishment) and consultant radiologists (3.85 whole time equivalents below the establishment). Leaders told us there were 100 consultants working within imaging (across multiple sites). Realistically, the whole service required 130 consultants in total to cover all the increased and rising demand. Staff told us recruitment had improved and was a lot more efficient now. However, as the service operated 24 hours a day, staffing levels were addressed with the use of bank and locum staff to ensure there was safe cover.

The service had low levels of sickness and turnover. The current sickness rate 4.8% which included long and short-term sickness. This was just higher (worse than) the trust target of 4%. Information showed the sickness level for administration and clerical staff was the highest at 8.6%. Sickness management was a specific area of focus at the service’s people and culture committee meeting. Turnover for the service was currently 6.6% which is below (better than) the trust target of 9%, except for administrative and clerical staff which was recorded at 16.2%.

Staff were suitably qualified and competent to carry out their roles. There were competency frameworks for each allied healthcare professional’s role in the imaging team. Staff described how they were assessed by their supervisors against the criteria and required to maintain their core competencies. Staff talked about being encouraged and enabled to progress into new roles and many in the department were progressing through training and education or had done so at the hospital. International allied health professionals were employed against an equivalent competency framework and given the same opportunities to develop and progress.

Staff updated mandatory training to be able to deliver their roles in accordance with current practice and safely. Overall, compliance with mandatory training was 90.6% which was meeting the trust target of 90%. There were some topics which were just below the target which included manual handling, clinical life support and fire safety. Managers were aware of where compliance was challenged and worked with the service’s education team to address this.

Most staff were receiving annual reviews, although overall the service was just below the trust target. Staff told us they mostly had annual reviews of their competencies (appraisals) with their managers and had opportunities to discuss their learning and development needs. However, there was a long-standing vacancy for one of the managers supporting the administration team and not all staff in this area felt support was a good as it should be. The overall compliance with appraisals was 82.7% which was below the trust target of 90%. Administration and clerical staff had the lowest compliance of 45.8% which was evidence of what staff told us during our inspection about their support. Information showed other areas which were significantly lower than the trust target had been impacted by the service pressures as well as sickness. There was a plan to ensure this was addressed and oversight of the progression was reviewed at the monthly imaging workforce and training meeting.

Students who were considering a career in radiology or other imaging areas were supported and encouraged to spend time learning in each modality. The service had its own practice placement manager and educational links to support students during their clinical placements.

Managers used bank, agency or locum staff to support vacancies or unfilled shifts. Most staff we spoke with raised concerns about the demand on their services and requirements to try and expand the lists provided. An example of this was within mammography who were completing weekend lists to support the demand for imaging. This had meant where staff were unable to support the additional lists, they had required the use of bank and agency staff. Between October 2025 and March 2026 there had been 1,503 shifts covered by bank staff. The majority related to imaging assistants who supported most areas and modalities, in particular ultrasound. Between the same period of time, there had been 66 shifts covered by agency staff within breast imaging and ultrasound and 54 sessions covered by locum consultants of which 41 sessions were recorded as reporting sessions.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading through evidence-based infection prevention and control practice.

Most staff adhered to infection control principles. However, not all medical staff entered the clinical areas ‘bare below the elbow’ (to support safe and effective hand-washing). We observed some entering a clinical area wearing gloves which were being used when they arrived in the area with the patient. Most staff wore gloves and aprons when required, but we observed an over-reliance on gloves in some circumstances where they were not required to be worn.

People were protected as much as possible from the risk of infection because premises and most equipment was kept clean and well-maintained. Areas we visited were visibly clean and tidy and organised in such a way as to be straightforward to clean. Specialist equipment was cleaned by the clinical staff, and we observed anything which had contact with a member of staff or a patient being cleaned afterwards. However, some of the chairs in the CT scan room used by staff were considerably cracked and posed an infection risk from ineffective cleaning.

The service completed audits to provide assurance that patients were provided with safe care in line with infection prevention and control standards. Staff completed national cleaning audits monthly, results were recorded between 94.6% and 97.1% which were mostly in line with the target of 95%. Where areas of non-compliance were identified, reports were shared with all relevant teams that identified specific areas of failure to be addressed.

Staff working in imaging wore visibly clean uniforms or scrubs and those we met all met the trust’s dress-code standards. This included being bare below the elbow to allow for good handwashing, short nails and limited jewellery. However, we did not see staff challenge a doctor who entered a clinical area without being bare below the elbow or using any gel to clean their hands. We requested hand hygiene audits as part of the data requested after the inspection, but no audits were shared.

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

The approach to medicines reflected current and relevant evidence-based practice and professional guidance. Medicines used in diagnostic imaging, including contrast media and radiopharmaceuticals were stored securely, checked regularly and administered safely. Radiopharmaceuticals were delivered to the department daily and were checked by 2 radiographers. The service underwent medicines audits to ensure staff were safely managing all medicines including controlled drugs (medicines requiring more control due to their potential for abuse). The most recent controlled drugs audit completed in September 2025 showed 100% compliance. The most recent safe and secure handling of medicines audit was completed between August and October 2025 and scored between 95 and 100% compliance with legislation and regulation and best practice standards. Where areas of non-compliance were observed, reports were sent to the department to take action.

Emergency medicines were available in the department and were checked regularly along with the resuscitation equipment. Staff also had access to an anaphylaxis kit for patients who suffered from an allergic reaction to contrast (a substance to highlight soft tissues, blood vessels and organs).

Staff were knowledgeable about contraindications and screened patients for allergies and medical history prior to undertaking their procedures.