Royal Shrewsbury Hospital

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• 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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We have not previously assessed this key question for Diagnostic Imaging as a standalone service. At this assessment we rated safe as Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent. There was a breach of regulation around turnaround times for some examinations.

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.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Referrers could include information about patients’ needs in referrals. Clerical staff telephoned most patients before their examinations and took this opportunity to further assess patients’ needs. Flags were added to the radiology information system to communicate needs such as a patient requiring an interpreter, or difficulty in obtaining intravenous access. Staff assessed patient mobility and had access to aids such as walking frames to meet their needs.

We scored the service as 3. 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 and current evidence-based good practice and standards.

Staff had access to up-to-date policies, procedures and guidance which were in line with legislation and current evidence-based good practice and standards through a shared computer drive. Staff in computed tomography in the main X-ray department also kept a folder of paper copies of protocols, some of which were not the latest version. This was fed back to staff at the time. Staff in each modality could demonstrate how to access examination protocols, local rules, and where applicable dose reference levels, in line with Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017. New staff signed an IR(ME)R 2017 and Ionising Radiations Regulations 2017 declaration as part of their induction pack. Staff had access to local radiation protection supervisors, who had undergone the required training, and radiation protection advisers and medical physics experts based at another hospital trust. Local rules for X-Ray were being updated at the time of inspection, after which staff will be required to re-sign a declaration that they had read and understood the updated rules. Staff in ultrasound said they used local safety standards for invasive procedures when performing interventional examinations. Although leaders did not have access to a formal document management system, documents were saved in formats that did not allow for unauthorised editing.

We observed posters for the Society of Radiographers’ ‘Pause and Check’, a checklist to prompt staff to ensure the right patient was receiving the right examination, in work areas. Staff adhered to the checklist, including checking patient identification and anatomical area.

Radiologists and reporting radiographers participated in radiology events and learning meetings in line with Royal College of Radiologists guidance.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people.

Teams had effective working relationships, and we observed staff working co-operatively to support people. Clinical staff spoke highly of the patient transport team, a dedicated portering team for radiology, and their effect on service efficiency. Staff held daily ‘huddles’ to share information and updates. However, staff in magnetic resonance imaging (MRI) said that they were not always in attendance of huddles and tended to hear about updates through ‘word of mouth’. The service held regular open forums for staff to meet by job role, for example, band 5 radiographers. Staff were able to dial into forums online if they were unable to attend in person, and meeting summaries were sent to staff by email. Leaders found that whole service team meetings were poorly attended due to staffing requirements to continue services, and so these meetings happened less frequently.

We heard about how staffing factors outside of radiology impacted on the service provided. Staff told us, and we saw incident reports showing, that staffing issues in the radiopharmacy had a knock-on effect on the nuclear medicine service, with a lack of radiopharmaceutical availability causing patient cancellations. The service had recently introduced MRI lists for patients with pacemakers, a patient group usually excluded from the modality. Staff told us they relied on cardiac physiologists from the Princess Royal site to put devices into MRI safe mode but due to short staffing, they had also had to cancel lists. However, staff spoke highly of the support they received from medical physics experts at another hospital trust.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service had posters in waiting areas displaying relevant information about diagnostic tests. Due to the nature of the service, there were limited opportunities for staff to provide health advice or support, but resources were available on the trust’s public website. This included advice on smoking cessation, mental wellbeing and keeping active.

We scored the service as 2. The evidence showed some shortfalls. The service routinely monitored people’s care and treatment to continuously improve it. However, outcomes were not always positive and consistent to meet both clinical expectations and expectations of people themselves.

The service had a scheduled programme of audits to monitor performance including annual audits on consent, adherence to pregnancy checking procedures in line with Ionising Radiation (Medical Exposure) Regulations 2017, dose reference levels, and use of radiographic markers. Leaders told us that audits had been introduced to provide assurance in response to incidents, such as a vetting audit in nuclear medicine, and also gave an example of action from a surgical laparotomy audit outside of radiology whereby all acute computed tomography abdomen examinations were peer reviewed, and addendums added where necessary. There were also rolling peer review programmes for radiologists, reporting radiographers and sonographers. A standard operating procedure was in place for the monitoring of image quality, where reporting radiographers provided individuals feedback on any suboptimal imaging, or any imaging of an exceptional standard. Where individuals had 3 recorded examples of suboptimal imaging within a rolling year period, an action plan was initiated.

Leaders monitored waiting times for examinations and turnaround times for reporting. They aimed to update referrers on performance monthly. We viewed the latest data and while some waiting and report turnaround times met or were close to meeting target times, for example 2 week wait ultrasound and fluoroscopy examinations were completed and reported within 1 to 2 weeks, other examinations did not meet target times. According to NHS England guidance, no verified report should take longer than 4 weeks to be provided after image acquisition, under any circumstance. All outpatient plain X-Ray examinations including 2 week wait referrals had a 5 week reporting time at the time of inspection. Waiting time for computed tomography (CT) cardiac scans was 27 weeks, with a total turnaround time of 29-30 weeks. Staff cited a lack of cardiologist availability as a barrier to cardiac CT examinations taking place. Leaders spoke about work they had and were currently undertaking to improve performance. As well as outsourcing reporting to third party providers, the service was recruiting to the advanced practice radiographer reporting team, although staff told us that radiologists having time to train reporting radiographers was a barrier. The trust had recently opened a community diagnostic centre to increase scan capacity.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

We observed staff explaining examinations to patients before gaining informed consent to proceed. All of the patients we spoke with said that staff explained their treatment to them in a way they could understand. Staff completed mandatory training on mental capacity and deprivation of liberty safeguards, although at the time of inspection compliance was below target level at 76%. Where patients did not have capacity to complete safety questionnaires for magnetic resonance imaging (MRI), staff worked with patients’ next of kin to complete them. Where next of kin were unable to assist, radiographers worked with radiologists and referring clinicians to assess patients’ medical history to ensure they were safe for MRI in their best interest.