InHealth Ealing NewApproachFocused Report … · 2019-08-02 · Efficiency models from...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective?

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

InHeInHealthalth EalingEalingQuality Report

Lovelace House,96-122 Uxbridge road,W13 8RBTel: 0333 202 3188Website: www.inhealthgroup.com

Date of inspection visit: 27 February 2019Date of publication: 18/07/2019

1 InHealth Ealing Quality Report 18/07/2019

Letter from the Chief Inspector of Hospitals

InHealth Ealing is operated by InHealth. The service provides diagnostic imaging services to the local community. It is astand-alone purpose-built diagnostic screening facility.

InHealth was established 25 years ago to meet some of the health economy’s challenges – reducing waiting times,speeding up diagnoses, saving money, improving patient pathways and enhancing the overall patient experience.Efficiency models from manufacturing programmes were adapted to develop healthcare services focused oncontinuous quality improvement. The organisation was successful in winning contracts and has grown due to its accessto capital for investment, its ability to design and adapt healthcare solutions to meet changing demands, demonstratevalue for money and to work collaboratively with its NHS and private sector partners.

InHealth Ealing provides magnetic resonance imaging (MRI), X-ray and dual-energy X-ray absorptiometry (DEXA) scansfor both NHS and private patients. DEXA uses a very small dose of ionising radiation to produce pictures of the inside ofthe body to measure bone loss (medical use), or body fat (composition scans only i.e. gyms). The service is registeredwith the CQC to undertake the regulated activities of diagnostic and screening procedures. The site provides a servicefor patients aged 16 and above. The site operates 6 days a week between the hours of 7am and 9pm and 8am to 8pm onthe remaining day.

InHealth Ealing also housed three clinical rooms which provided peripatetic routine ultrasound, physiologicalmeasurements,echocardiogram, abdominal aortic aneurysm (AAA) screening which was managed by separateregistered managers under a separate registration number. InHealth Ealing also comprised of an endoscopy unit whichopened in 2015 and is located within the InHealth Integrated Diagnostics Centre suite and is delivered under a separateCQC registration. All services other than MRI, X-ray and DEXA at InHealth Ealing are provided on an ad-hoc basis byInHealth and managed by a separate registered manager employed by InHealth.

We inspected this service using our comprehensive inspection methodology. We carried out the unannouncedinspection on 27 February 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

The main service provided by this centre was diagnostic imaging.

Services we rate

We rated InHealth Ealing as Good overall.

We found good practice in relation to diagnostic imaging:

• Staff received effective training in the safety systems, processes and practices.• There were sufficient numbers of staff with the necessary skills, experience. Patients had their needs assessed and

their care and treatment was planned and delivered in line with evidence-based guidance, standards and bestpractice and qualifications to meet patients’ needs.

• There was a programme of mandatory training which all staff completed, and systems for checking staffcompetencies.

• Equipment was maintained and serviced appropriately and the environment was visibly clean.• There was evidence of regular team meetings.

Summary of findings


• Staff were caring, kind and engaged with patients.• We observed a focused and individual approach to patient care.• Scans were timely, effective and reported promptly.• Information about the needs of the local population was used to inform how services were planned and delivered.• Leaders had the skills, knowledge, experience and integrity needed, both when they were appointed, and on an

ongoing basis.• Staff understood and were invested in the vision and values of the organisation.• Risks were identified, assessed and mitigated. Performance was monitored and performance information was used

to make improvements.

Nigel AchesonDeputy Chief Inspector of Hospitals

Overall summary

InHealth Ealing is operated by InHealth. The serviceprovides diagnostic imaging services to the localcommunity. It is a stand-alone purpose-built diagnosticscreening facility.

InHealth was established 25 years ago to meet some ofthe health economy’s challenges – reducing waitingtimes, speeding up diagnoses, saving money, improvingpatient pathways and enhancing the overall patientexperience. Efficiency models from manufacturingprogrammes were adapted to develop healthcareservices focused on continuous quality improvement.The organisation was successful in winning contracts andhas grown due to its access to capital for investment, itsability to design and adapt healthcare solutions to meetchanging demands, demonstrate value for money and towork collaboratively with its NHS and private sectorpartners.

InHealth Ealing provides magnetic resonance imaging(MRI), X-ray and dual-energy X-ray absorptiometry (DEXA)scans for both NHS and private patients. DEXAuses a verysmall dose of ionising radiation to produce pictures of theinside of the body to measure bone loss (medical use), orbody fat (composition scans only i.e. gyms). The service isregistered with the CQC to undertake the regulatedactivities of diagnostic and screening procedures. Thesite provides a service for patients aged 16 and above.The site operates 6 days a week between the hours of7am and 9pm and 8am to 8pm on the remaining day.

InHealth Ealing also housed three clinical rooms whichprovided peripatetic routine ultrasound, physiologicalmeasurements,echocardiogram, abdominal aortic

aneurysm (AAA) screening which was managed byseparate registered managers under a separateregistration number. InHealth Ealing also comprised of anendoscopy unit which opened in 2015 and is locatedwithin the InHealth Integrated Diagnostics Centre suiteand is delivered under a separate CQC registration. Allservices other than MRI, X-ray and DEXA at InHealth Ealingare provided on an ad-hoc basis by InHealth andmanaged by a separate registered manager employed byInHealth.

We inspected this service using our comprehensiveinspection methodology. We carried out theunannounced inspection on 27 February 2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

The main service provided by this centre was diagnosticimaging.

Services we rate

We rated InHealth Ealing as Good overall.

We found good practice in relation to diagnostic imaging:

Summary of findings


• Staff received effective training in the safety systems,processes and practices.

• There were sufficient numbers of staff with thenecessary skills, experience. Patients had their needsassessed and their care and treatment was plannedand delivered in line with evidence-based guidance,standards and best practice and qualifications to meetpatients’ needs.

• There was a programme of mandatory training whichall staff completed, and systems for checking staffcompetencies.

• Equipment was maintained and servicedappropriately and the environment was visibly clean.

• There was evidence of regular team meetings.• Staff were caring, kind and engaged with patients.• We observed a focused and individual approach to

patient care.• Scans were timely, effective and reported promptly.• Information about the needs of the local population

was used to inform how services were planned anddelivered.

• Leaders had the skills, knowledge, experience andintegrity needed, both when they were appointed, andon an ongoing basis.

• Staff understood and were invested in the vision andvalues of the organisation.

• Risks were identified, assessed and mitigated.Performance was monitored and performanceinformation was used to make improvements.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Diagnosticimaging Good –––

The service provided at this location wasdiagnostic and screening procedures.We rated this core service as good overall because itwas safe, caring, responsive and well-led.

Summary of findings


Contents

PageSummary of this inspectionBackground to InHealth Ealing 8

Our inspection team 8

Information about InHealth Ealing 8

The five questions we ask about services and what we found 10

Detailed findings from this inspectionOverview of ratings 13

Outstanding practice 30

Areas for improvement 30

Action we have told the provider to take 31

Summary of findings


Inhealth Ealing

Services we looked atDiagnostic imaging

InhealthEaling

Good –––


Background to InHealth Ealing

This report relates to MRI, X-ray and DEXA servicesprovided by InHealth Ealing. The service primarily servesthe communities of the London Borough of Ealing.However, it also accepts patient referrals from outsidethis area.

InHealth Ealing was previously inspected on 20 August2013 using the CQC previous methodology. We did notrate the service using this methodology. However, theservice was found to have met the CQC essentialstandards.

InHealth was established over 25 years ago. The Ealingcentre provides MRI, X-ray and DEXA examinations tomainly patients referred from the NHS through clinicalcommissioning group (CCG) contracts directly withInHealth and some private patients. The service workscollaboratively with CCGs and local GP services. Thecentre provides services for young people and adults overthe age of 18 years old.

Our inspection team

The team that inspected the service comprised a CQClead inspector and a specialist advisor with expertise indiagnostic imaging. The inspection team was overseen byTerri Salt, Interim Head of Hospital Inspections NorthLondon.

Information about InHealth Ealing

InHealth Ealing is situated in Lovelace House, 96 – 122Uxbridge Road, West Ealing. The service is situated in apurpose build commercial building which was retrofittedfor providing the services described. InHealth Ealingopened in 2013 and provides a seven-day a week servicefor non-complex, non-contrast enhanced routine MRIscanning via a 1.5 Tesla Siemens MRI scannerto predominately the NHS and private sector. InHealthEaling also offers X-ray and DEXA scans.

No patients under the age of 18 are seen at the site andtherefore there are no separate paediatric facilities.

The scheduling of services is reviewed and revised on amonthly basis in accordance with the local clinicalcommissioning groups (CCG) contracts andCommissioning for Quality and Innovation (CQUINS)goals.

Appointments for MRI, X-ray and DEXA scans can beprebooked through the InHealth patient referral centre(PRC) once a referral has been received from the patient’sclinician.

InHealth Ealing has facilities offering three clinical roomsproviding peripatetic routine ultrasound, physiologicalmeasurements,echocardiogram, AAA screening which ismanaged by separate registered managers under aseparate registration number. InHealth Ealing alsocomprises an endoscopy unit which opened in 2015 andis located within the InHealth IntegratedDiagnostics Centre suite and delivered under a separateCQC registration. All clinical rooms and the MRI unit arelocated on the ground floor.

InHealth Ealing is registered to provide the followingregulated activities:

• Diagnostic and screening procedures

During the inspection, we spoke with five staff includingthe registered manager, radiographers, superintendantradiographers, clinical assistants and administration staff.We spoke with three patients and two relatives. Duringour inspection, we reviewed eight sets of patient records.

Summaryofthisinspection

Summary of this inspection


There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection. This was the services firstinspection with new methodology, which found that theservice was meeting all standards of quality and safety itwas inspected against.

Activity (November 2017 to November 2018)

Track record on safety

• No never events, clinical incidents or serious injuries.• No incidences of healthcare acquired

Meticillin-resistant Staphylococcus aureus (MRSA),Meticillin-sensitive staphylococcus aureus (MSSA),Clostridium difficile (c.diff) or healthcare acquiredE-Coli

• Five formal complaints of which three were upheld.

Services accredited by a national body:

• Investors in People Gold award - December 2016 toDecember 2019.

• ISO 9001: 2015 – December 2001 to December 2019

• International Organization for Standardization (ISO -information security management systems – ISO27001 2013 - August 2013 to December 2019

• Improving Quality in Physiological Services (IQIPS)adult and children’s physiology- July 2016 to July 2021

Services provided at the hospital under service levelagreement:

• Premises rental agreement• Building maintenance• Clinical and or non-clinical waste removal• Interpreting services• Laundry• Maintenance of medical equipment• Radiology reporting




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated it as Good because:

• The service provided mandatory training in key skills to all staffand made sure everyone completed it.

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so.

• Staff completed and updated risk assessments for each patient.Ionising radiation risks were well managed.

• The service had enough staff with the right qualifications, skills,training and experience to keep people safe from avoidableharm and to provide the right care and treatment.

• There was an open incident reporting culture within the centreand an embedded process for staff to learn from incidents.

• Standards of cleanliness and hygiene were maintained.• Staff were compliant with best practice regarding hand hygiene.• There were comprehensive risk assessments carried out for

people who use services and risk management plansdeveloped in line with national guidance.

Good –––

Are services effective?We currently do not rate effective, we found:

• Patients had their needs assessed and their care and treatmentwas planned and delivered in line with evidence-basedguidance, standards and best practice.

• There were systems to show whether staff were competent toundertake their jobs and to develop their skills or to manageunder-performance.

• There was effective multidisciplinary team working throughoutthe centre and with other providers.

• Information leaflets such as understanding your CT scan,understanding your MRI scan were sent to patients with theirappointment letters and were available in the waiting rooms.

• Staff had the right qualifications, skills, knowledge andexperience to do their job when they started their employment,took on new responsibilities and on a continual basis.

• Information provided by the centre demonstrated 100% of staffhad been appraised.

• Staff understood the relevant consent and decision-makingrequirements of legislation and guidance, including the MentalCapacity Act 2005.




• We observed all staff treating patients with dignity, kindness,compassion, courtesy and respect.

• Staff understood the impact that a patient’s care, treatment orcondition had on their wellbeing and on their relatives.

• We observed staff communicating with patients so that theyunderstood their care, treatment and condition.

• Staff recognised when patients and those close to them needadditional support to help them understand and be involved intheir care and treatment and enable them to access this.

Are services caring?We rated it as Good because:

• We observed all staff treating patients with dignity, kindness,compassion, courtesy and respect.

• Staff understood the impact that a patient’s care, treatment orcondition had on their wellbeing and on their relatives.

• We observed staff communicating with patients so that theyunderstood their care, treatment and condition.

• Staff recognised when patients and those close to them needadditional support to help them understand and be involved intheir care and treatment and enable them to access this.

Good –––

Are services responsive?We rated it as Good because:

• Information about the needs of the local population was usedto inform how services were planned and delivered.

• Services were planned to take account of the needs of differentpeople.

• Patients had timely access to scanning.• Patients we spoke with knew how to make a complaint or raise

concerns.• Patient complaints and concerns were managed according to

the InHealth policy.• Complaints were investigated and learning was identified and

shared to improve service quality.

Good –––

Are services well-led?We rated it as Good because:

• The service had a clear vision and a set of values, with qualityand safety the top priority.

• Staff felt respected and valued. Staff told us they felt supported,respected and valued by the organisation.

• There was an effective governance framework to support thedelivery of the strategy and good quality care.

Good –––




• The service had a local risk register and managers had clearvisibility of the risks and were knowledgeable about actions tomitigate risks.

• There was a culture of openness and honesty supported byfreedom to speak up guardians.

• Patients’ views and experiences were gathered and acted on toshape and improve the services and culture.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Diagnostic imaging Good N/A Good Good Good Good

Overall Good N/A Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective

Caring Good –––

Responsive Good –––

Well-led Good –––

Are outpatients and diagnostic imagingservices safe?

Good –––

Mandatory training

• The service provided mandatory training in keyskills to all staff and made sure everyonecompleted it.

• Staff completed a set of annual mandatory e-learningcourses, and face to face training internally or viacontracting organisations to cover basic life support(BLS), moving and handling and fire training.

• Staff training files included a contemporaneous trainingrecord. This included details of training undertakenincluding; fire safety and evacuation, health and safetyin healthcare, equality and diversity, infectionprevention and control, moving and handling objectsand moving and handling people/patients,safeguarding adults and children, customer care andcomplaints, basic life support (BLS) and data securityawareness.

• Mandatory training rates were regularly reviewed atquarterly team meetings. At the time of this inspection,all staff had completed and were up to date withmandatory training.

• Mandatory training was monitored at corporate level byInHealth. Staff received email alerts from the company’slearning and development team when mandatorytraining was due. The InHealth head of operations forLondon monitored mandatory training rates at regularquarterly managers meetings.

Safeguarding

• Staff understood how to protect patients fromabuse and the service worked well with otheragencies to do so.

• Staff were trained to recognise adults at risk and weresupported by the InHealth safeguarding adults’ policy.Staff we spoke with demonstrated that they understoodtheir responsibilities and adhered to the company’ssafeguarding policies and procedures.

• At the time of this inspection, all staff had receivedsafeguarding adults and safeguarding children level 2training.

• Although the service did not scan children, all staff hadreceived training in safeguarding children and youngpeople level two, as it was possible children couldattend with patients. This met intercollegiate guidance:‘Safeguarding Children and Young People: Roles andcompetencies for Health Care Staff’, March 2014.Guidance states all non-clinical and clinical staff thathave any contact with children, young people, parentsor carers should be trained to level two safeguarding.

• The lead for safeguarding was the nominated individualwho was trained to level four children’s and adultssafeguarding. (This was a staff member nominated byInHealth to act as the company’s main point of contactwith the CQC).

• Staff we spoke with were aware of the Department ofHealth (DoH) female genital mutilation andsafeguarding guidance for professionals March 2016.

• InHealth Ealing did not provide services for childrenunder the age of 17 years. However, we saw contact

Diagnosticimaging

Diagnostic imaging

Good –––


numbers for local adult and child safeguarding teamreferrals were in the unit’s office. The contact details forthe InHealth safeguarding team were also located in theoffice.

• A weekly complaints, litigation, incidents andcompliments (CLIC) meeting and InHealth’s biannualsafeguarding boards monitored compliance withsafeguarding policies and raising concerns processes.The boards identified themes from incidents and setimprovement goals.

Cleanliness, infection control and hygiene

• The service controlled infection risk well.

• InHealth had infection prevention and control (IPC)policies and procedures which provided staff withguidance on appropriate IPC practice for example,communicable diseases and isolation.

• We observed all areas of the service to be visibly clean.The centre team cleaned the MRI room at the end ofeach day. This was recorded on a daily check sheetwhich was reviewed by the registered manager eachweek.

• Staff followed manufacturers’ instructions and theInHealth IPC guidelines for routine disinfection. Thisincluded the cleaning of medical devices between eachpatient and at the end of each day. We saw staffcleaning equipment and machines following each use.

• We reviewed all machines in use, and saw whereappropriate the machines had been disinfected.

• All the patients we spoke with were positive about thecleanliness of the centre and the actions of the staff withregards to infection prevention and control.

• All the staff we observed demonstrated compliance withgood hand hygiene technique in washing their handsand using hand gel when appropriate. Staff were barebelow the elbow and had access to a supply of personalprotective equipment (PPE), including gloves andaprons. We saw staff using PPE appropriately.

• Hand hygiene audits were completed to measure staffcompliance with the World Health Organisation’s (WHO)‘5 Moments for Hand Hygiene.’ These guidelines are forall staff working in healthcare environments and definethe key moments when staff should be performing handhygiene to reduce risk of cross contamination between

patients. Results for the reporting period November2017 to November 2018 showed a compliance rate of100%. Hand hygiene results were communicated to staffthrough the centre’s staff meetings and via email.

• The registered manager was the IPC lead and wasresponsible for supporting staff, ensuring annual IPCcompetency assessments and training were carried outand undertaking IPC audits. IPC audits were completedmonthly. The cleaning audit spreadsheet demonstratedthat the centre regularly achieved above the InHealthcompliance standard of 80%. Where standards were notmet, actions were taken to rectify this and wererecorded on the cleaning audit spreadsheet.

• Waste was handled and disposed of in a way that keptpeople safe. Waste was labelled appropriately and stafffollowed correct procedures to handle and sort differenttypes of waste.

Environment and equipment

• The service had suitable premises and equipmentand looked after them well.

• The MRI unit was located on the ground floor. This had ascanning observation area which ensured patients werevisible to staff during scanning.

• The fringe fields around the MRI scanner were clearlydisplayed, (this is the peripheral magnetic field outsideof the magnet core. This reduces the risk of magneticinterference with nearby electronic devices, such aspacemakers. Although the strength of the magneticfields decreases with distance from the core of themagnet, the effect of the “fringe” of the magnetic fieldcan still be relevant and have influence on externaldevices). There were diagrams in the observation areawhich clearly defined the MRI environment andcontrolled access areas by colour coding the areas.

• Staff had sufficient space to move around the scannerand for scans to be carried out safely. During scanningall patients had access to an emergency call alarm, earplugs and ear defenders. Patients could have radiostations of their choice played whilst being scanned.There was also a microphone that allowed contactbetween the radiographer and the patient at all times.

• In accordance with Medicines and Healthcare productsRegulatory Agency (MHRA) guidance, 5.4.6, scanningrooms were equipped with oxygen monitors to ensure

Diagnosticimaging

Diagnostic imaging

Good –––


that any helium gas leaking (quench) from the cryogenicDewar (this is a specialised type of vacuum flask usedfor storing cryogens such as liquid nitrogen or liquidhelium), would not leak into the examination room, thusdisplacing the oxygen and compromising patient safety.The scanning room was also fitted with an emergencyquench switch which was protected against accidentaluse and initiated a controlled quench and turned off themagnetic field in the event of an emergency. Themagnet was also fitted with emergency “off” switches,which suspend scanning and switch off power to themagnet sub-system, but will not quench the magnet.Staff we spoke with were fully aware of actions requiredin the event of an emergency quench situation.

• An MRI safe wheelchair and trolley were available forpatients in the event that they would need to betransferred from the scanner in an emergency.

• All equipment conformed to relevant safety standardsand was regularly serviced. All non-medical electricalequipment was electrical safety tested. We viewedservicing records for the MRI scanner. These includeddowntime and handover time.

• There were systems in place to ensure repairs tomachines or equipment were completed and thatrepairs were timely. This ensured patients would notexperience prolonged delays to their care and treatmentdue to equipment being broken and out of use.Servicing and maintenance of premises and equipmentwas carried out using a planned preventativemaintenance programme.

• During our inspection we checked the service dates forequipment, including scanners. All the equipment wechecked was within the service date. The generatorswere also tested monthly on a planned schedule toensure patient scanning was not affected.

• Failures in equipment and medical devices werereported through the InHealth technical support team.Staff told us there were usually no problems or delays ingetting equipment repaired. Equipment breakdown waslogged on the InHealth incidents log to enable thecompany in monitoring the reliability of equipment.

• We checked the resuscitation equipment on the MRIunit. The equipment appeared visibly clean. Single-useitems were sealed and in date, and emergencyequipment had been serviced.

• Records indicated resuscitation equipment had beenchecked daily by staff and was safe and ready to use inthe event of an emergency.

• There were procedures in place for removal of a patientthat became unwell. Staff told us they had practiced theevacuation of a patient from the MRI and it had gonesmoothly using an MRI approved wheelchair.

• All relevant MRI equipment was labelled in accordancewith recommendations from the Medicines andHealthcare products Regulatory Agency (MHRA). Forexample, ‘MR Safe’, ‘MR Conditional’, ‘MR Unsafe’. Allequipment in the assessment area was labelled MRunsafe.

• Access to the MRI, X-ray and DEXA room was via a fobcontrolled door. There was signage on all doorsexplaining the magnet strength and safety rules and ado not enter sign when radiation was on.

• Room temperatures were recorded as part of the dailyMRI checks. We reviewed room temperature records onthe online daily check sheet and saw temperatures hadbeen checked and were within the required range. Wespoke with staff who told us that where temperatureswere not within the required range the scanner wouldnot work and this would be escalated to the registeredmanager and the service company automatically by theMRI scanner.

• Cleaning chemicals subject to the Control of SubstancesHazardous to Health Regulations 2002 (COSHH) werestored in a locked cupboard.

• The superintendent had a daily equipment check sheetthat was completed prior to scanning. This includedchecks on the availability of earplugs and couch rollsand checks on the defibrillator.

• We reviewed the quarter four, environment and healthand safety audit. We found compliance with InHealthkey performance indicators (KPI) was 100% in all areas.

Assessing and responding to patient risk

• Staff completed and updated risk assessments foreach patient. Ionising radiation risks were wellmanaged.

• Staff assessed patient risk and developed riskmanagement plans in accordance with nationalguidance. For example, the unit used a magneticresonance imaging patient safety questionnaire. Riskswere managed positively and updated appropriately toreflect any change in the patient’s condition including

Diagnosticimaging

Diagnostic imaging

Good –––


managing a claustrophobic patient. Patients referralswere checked at the point of referral for any potentialMRI safety alerts that required further investigation. Forexample, whether the patient had any implants ordevices. Patient with implants or devices would bedeclined an appointment by the patient referral centre(PRC) until it was established with the referrer that thesewere MRI safe.

• Patients had the choice of wearing their own clothes orchanging into a gown prior to the scan. Most of thepatients we saw during the inspection changed into agown. All patients told us they were given information,were risk assessed and had signed a form to accept theyhad understood the risks in regards to their choice ofclothing and MRI scanning.

• There were clear pathways and processes for staff toassess people using services that were clinically unwelland needed to be admitted to hospital. For example, theInHealth routine MRI guidance policy was available toguide staff in referring patients to an emergencydepartment for conditions related to the brain andspine. Patients that became unwell in the unit would bereferred to their GP. Staff told us that if a patientrequired more urgent treatment they would call 999.

• The service ensured that the ‘requesting’ of an MRI wasonly made by staff in accordance with the MHRAguidelines. All referrals were made using dedicated MRIreferral forms which were specific to the contract withthe commissioning group. All referral forms includedpatient identification, contact details, clinical historyand the type of examination requested, as well asdetails of the referring clinician/ practitioner.

• Signs were located throughout the unit in both wordsand pictures highlighting the contraindications to MRIincluding patients with heart pacemakers, patients whohad a metallic foreign body in their eye, or who had ananeurysm clip in their brain could not have an MRI scanas the magnetic field may dislodge the metal. There wasalso signage informing patients and visitors of themagnet size and informing that the magnet wasconstantly on.

• Staff we spoke with explained the processes to escalateunexpected or significant findings both at theexamination and upon reporting. These were inaccordance with InHealth routine MRI guidance policy.

InHealth had a pathway for unexpected urgent clinicalfindings. In the case of NHS patients, an urgent reportrequest was sent to the external reporting provider.Once the report was received (within 24 hours), an emailwas sent to the referrer to highlight an urgent report. Inaddition to this, InHealth picture archiving andcommunication system (PACS) team also contacted thereferrer by phone to inform them an urgent report hadbeen sent and the person who was spoken with at thereferring service was recorded on the database. Theywere asked to verbally acknowledge that an email withthe report had been received. If the patient was a privatepatient, the reporting radiologist was contacted by amember of staff to advise them of the urgent report toensure it received prompt attention. If at time of scan,the radiographers thought the patient needed urgentmedical attention, the patient was advised to attendaccident and emergency department. All images wouldbe sent to the referrer urgently via the image exchangeportal to assist in patient management.

• There were processes to ensure the correct person gotthe correct radiological scan at the right time. Theservice had a Society of Radiographers (SoR) posterwithin the unit. The posters acted as an aide memoirefor staff reminding them to carry out checks on patients.

• We also saw staff using the SoR “paused and checked”system. Referrer error was identified as one of the maincauses of incidents in diagnostic radiology, attributed to24.2% of the incidents reported to the CQC in 2014. Thesix-point check had been recommended to help combatthese errors. Pause and Check consisted of thethree-point demographic checks to correctly identify thepatient, as well as checking with the patient the site orside of their body that was to have images taken, theexistence of any previous imaging the patient hadreceived and to enable the MRI operator in ensuring thatthe correct imaging modality was used.

• All clinical staff were basic life support (BLS) andautomated external defibrillator (AED) trained. In theevent of a cardiac arrest for young people over the ageof 16 years InHealth would receive adult resuscitationprocedures.

• Staff told us there was no lone working at the centre.

• The recruitment process for radiographers includedpre-employment checks to provide assurances that they

Diagnosticimaging

Diagnostic imaging

Good –––


were safe and suitable to work for the service. Theseincluded, proof of identity including a recentphotograph, a Disclosure and Barring Service (DBS)check, references and registration with the Health andSocial Care Professional Council (HCPC). Staff told usthe InHealth human resources (HR) departmentcompleted all pre-employment checks and staff wouldnot be given a date to commence employment at thecentre until these checks were complete. However, wedid not see any pre-employment checks to confirm thisas these were held by the InHealth HR team at thecompany’s head office.

Staffing

• The service had enough staff with the rightqualifications, skills, training and experience tokeep people safe from avoidable harm and toprovide the right care and treatment.

• InHealth used a ‘staffing calculator’, designed to takeaccount of expected, and a degree of unexpected,absences; ensuring sufficient staff availability across alloperational periods. Required staffing levels werecalculated using core service information including:operational hours, patient complexity and servicespecifications, physical layout and design of the facility/service, expected activities, training requirements, andadministrative staffing requirements. Staffing levels hadbeen set following working time studies and analysis ofaverage task time requirements. This ensured sufficientstaff to support patient and staff needs.

• The clinical coordinator was responsible for clinicalshifts being rostered in accordance with InHealth‘Health Working Time Regulations’ policy. The clinicalcoordinator was trained in rostering and used thestaffing tool to ensure safe staffing numbers. Theregistered manager was responsible for monitoring thehours worked by staff and ensuring they did not exceedworking time limits. This included ensuring staff workinglonger than six hours at a time received a 20-minute restbreak. Staff were entitled to a daily rest period of at least11 hours uninterrupted rest in every 24 hour period, aswell as a weekly rest period of 24 hours uninterrupted inevery seven day period.

• Staff in the centre consisted of one 0.3 whole timeequivalent (WTE) operations manager, one 0.3 WTE

clinical coordinator, one superintendent radiographer,three senior radiographers, one radiographer, onegraduate radiographer, one 0.3 WTE X-ray and DEXAradiographer and six clinical assistants.

• In the previous 12 months one clinical assistant, onetrainee radiographer and one X-ray and DEXAradiographer had left the service and these posts hadbeen successfully recruited to. At the time of inspectionthe centre had no vacancies.

• Agency staff were not used at InHealth Ealing. Shiftswere usually covered by the centre’s own staff. Thisensured staff continuity and familiarity with the centre.Business continuity plans guided the service inresponding to changing circumstances. For example,sickness, absenteeism and workforce changes. Staff toldus other InHealth locations could also provide staff inthe event of staffing shortages.

• Sickness rates in the previous 12 months were generallylow. The registered manager had not had any sicknessabsence in the previous 12 months. The clinicalco-ordinator had 7% sickness, radiographer was 4%,superintendent radiographer, clinical assistants,graduate radiographer and the DEXA and X-rayradiographer was 0%.

• All staff we spoke with felt that staffing was managedappropriately. Staff told us there was no lone working atthe centre and at all times there were at least two staffin the centre.

• The service did not employ any medical staff.Radiologists were provided by a service level agreement(SLA) with an external provider. Radiographers told usthey could contact an externally provided radiologist foradvice at any time.

Records

• Staff kept and updated individual patient carerecords in a way that protected patients fromavoidable harm.

• Patient care records were electronic and wereaccessible to staff.

• All patients were booked through InHealth’s patientreferral centre (PRC). The PRC was responsible for

Diagnosticimaging

Diagnostic imaging

Good –––


storing and maintaining patient records and sharingcommunications in regards to patients with relevantparties in accordance with the InHealth data protection,data retention, and confidentiality policies.

• Patients completed a safety consent checklist formconsisting of the patients’ answers to safety screeningquestions and also recorded the patients’ consent tocare and treatment. This was later scanned onto theelectronic system and kept with the patients’ electronicrecords.

• Patients’ personal data and information were keptsecure. Only authorised staff had access to patients’personal information. Staff training on informationgovernance and records management was part of theInHealth mandatory training programme.

• Staff completing MRI examinations, updated theelectronic records and submitted the scanned imagesfor reporting by an external radiologist. The centre had aservice level agreement with a private provider ofdiagnostic imaging reports. This included qualityassurance agreements in regards to the auditing ofreports to review the quality of images provided, clinicalerrors in the report, and a review of the quality of thetranscribed report.

• The quality of images was peer reviewed locally andquality assured on a corporate level. Any deficiencies inimages were highlighted to the member of staff for theirlearning.

• We reviewed eight patient care records during thisinspection and saw records were accurate, complete,legible and up to date. Paper records were shredded inaccordance with the InHealth policy once the paperbased information was uploaded onto the electronicrecords system.

• The service provided electronic access to diagnosticresults and could share information electronically ifreferring a patient to a hospital for emergency review.

• The service was also a registered user of the NHSelectronic referral system (ERS) The centre transferredpatient reports and images to referrers by secure picturearchiving and communication system (PACS). Theradiology information system (RIS) and PACS systemwas password protected.

• All the forms completed by patients were examined andtransferred electronically to the InHealth patientmanagement system (XRM), which was also accessibleby the InHealth patient referral centre (PRC) to enablefurther communication with referrers.

Medicines

• Medicines were not used at the service due to the centrehaving a remit to provide scanning for low risk patients.The service did not use contrast media (sometimescalled a MRI contrast media, agents or 'dyes'). These arechemical substances used in some MRI scans. A patientthat required the use of contrast would be referred toanother InHealth location.

• Patients received a letter prior to the procedure advisingthem to continue with their usual medicines regime. Allpatient allergies were documented and checked onarrival in the centre.

• InHealth had a consultant pharmacist who issuedguidance and support at a corporate level and workedcollaboratively with the InHealth clinical quality team onall issues related to medicines management. Staff toldus they could contact the InHealth pharmacist if theyhad any concerns in regards to medicines patients weretaking.

Incidents

• The service managed patient safety incidents well.• The service had an incident reporting policy and

procedure to guide staff in reporting incidents. Staffunderstood their responsibilities to raise concerns, torecord safety incidents, and investigate and record nearmisses. Staff reported incidents using an electronicreporting system.

• Staff told us learning from incidents was shared at theservices quarterly staff meetings. We saw evidence ofthis in minutes provided.

• During the reporting period there had been no seriousincidents requiring investigation, as defined by NHSI2015. Serious incidents are events in health care wherethe potential for learning is so great, or theconsequences to patients, families and carers, staff ororganisations are so significant, that they warrant usingadditional resources to mount a comprehensiveresponse.

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• There had been no ‘never events’ in the previous 12months prior to this inspection. Never events are seriousincidents that are entirely preventable as guidance, orsafety recommendations providing strong systemicprotective barriers, are available at a national level, andshould have been implemented by all healthcareproviders.

• There had been no notifiable safety incidents that metthe requirements of the duty of candour regulation inthe 12 months preceding this inspection. The duty ofcandour is a regulatory duty that relates to opennessand transparency and requires providers of health andsocial care services to notify patients (or other relevantpersons) of certain notifiable safety incidents andprovide reasonable support to that person.

• An InHealth organisational policy and procedure wasavailable to staff providing guidance on the process tofollow if an incident was to occur that met therequirements of the duty of candour regulation. All staffhad been trained and made aware of duty of candourand what steps to follow where it was required. Staff wespoke with understood the requirements of the duty ofcandour.

• The online incident reporting system generated a dutyof candour alert when a serious incident met the duty ofcandour requirements, this prompted staff to giveconsideration to them. Incidents involving patient orservice user harm were assessed with the ‘notifiablesafety incident’ criteria as defined within regulation 20of the Health and Social Care Act 2008 (regulatedactivities) Regulations 2014. Incidents meeting thisthreshold are managed under the organisations‘adverse events (incident) reporting and managementpolicy’ and ‘Duty of Candour procedure for thenotification of a notifiable safety incident’ standardoperating procedure.

• All incidents and complaints were reported via theorganisations electronic risk management system(Sentinel). Incidents were reviewed weekly at thegovernance complaints, litigation, incidents andcompliments (CLIC) meeting. The InHealth clinicalgovernance team analysed incidents and identifiedthemes and shared learning to prevent reoccurrence ata local and organisational level.

• National patient safety alerts (NPSA) that were relevantto the centre were communicated by email to all staff.All staff had to accept emails with mandatoryinformation which showed that they had been received.

Are outpatients and diagnostic imagingservices effective?

We do not rate effective.

Evidence-based care and treatment

• Staff used The Society of Radiographers (SoR) “Pausedand Checked” system. Referrer error was identified asone of the main causes of incidents in diagnosticradiology, attributed to 24.2% of the incidents reportedto the CQC in 2014. The six-point check had beenrecommended to help combat these errors. Pause andCheck consisted of the three-point demographic checksto correctly identify the patient, as well as checking withthe patient the site/side to be imaged, the existence ofprevious imaging and for the operator to ensure that thecorrect imaging modality is used.

• Patients care and treatment was delivered and clinicaloutcomes monitored in accordance with guidance fromthe National Institute for Health and Care Excellence(NICE). NICE guidance was followed for diagnosticimaging pathways as part of specific clinical conditions.For example, there was a pathway that met guidance inNICE CG75 Metastatic spinal cord compression in adults.

• Staff assessed patients’ needs and planned anddelivered patient care in line with evidence-based,guidance, standards and best practice. For example,staff followed the MHRA guidelines safety guidelines formagnetic resonance imaging equipment in clinical use.An audit was carried out annually to assess clinicalpractice in accordance with local and nationalguidance.

• Staff meetings were held on a quarterly basis. Minutesprovided showed InHealth policy was reviewed at eachmeeting.

• The centre had local rules based upon ‘Safety inmagnetic resonance imaging,’ (2013), guidelines. Wefound the local rules provided clear guidance on areasrelating to MRI hazards and safety and the

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responsibilities of MRI staff to ensure work was carriedout in accordance with the local rules. The DXA andX-ray unit had its own local rules with a suitable reviewdate. All local rules were displayed and in date.

Nutrition and hydration

• Patients had access to drinking water and a tea andcoffee making machine whilst awaiting theirexamination. During our inspection we observed staffoffering patients drinks before and after they wereexamined.

Pain relief

• Pain assessments were not undertaken at InHealthEaling. Patients managed their own pain and wereresponsible for supplying any required analgesia. Wewere told patients with a booking would receive a letterprior to the procedure advising them to continue withtheir usual medications.

Patient outcomes

• The service had a programme of audit to check thequality of procedures and the safety of the service.

• An external contractor performed a regular audit on allimage reporting undertaken by InHealth EalingDiagnostic Centre for NHS patients. All private patient’sscans were regularly audited by an outsourcedradiology reporting group. This was a 10% randomsample of total scans reported in a given period. Resultswere provided to the central clinical quality team. Alldiscrepancies were reported as a clinical incident intothe Sentinel incident reporting system.

• DXA imaging was reviewed daily through clinical qualityassurance and audited monthly by the seniorradiographer on site.InHealth quality audits wereundertaken annually and used to drive serviceimprovements. The centre had a clinical audit scheduleand audited 14 individual areas including, patientexperience, health and safety, medical emergency,safeguarding, equipment and privacy and dignity.

Competent staff

• All staff received a local and corporate inductionand underwent an initial competency assessment.

• The provider had a local induction checklist which wasmandatory for all new staff to complete within two

weeks of starting. The local induction ensured staff werecompetent to perform their required role. The localinduction included an introduction to the work location,health and safety, governance and code of conduct.

• Once the probationary period was complete staff weremonitored daily and any concerns were brought to theforefront immediately to ensure the correct corporatepath was followed. If there were any repeat area ofconcern, then a more formal discussion took place toensure their performance was always safe and effective.

• Staff had the opportunity to attend relevant courses toenhance the professional development and this wassupported by the organisation and local managers.

• Staff at the service, including non-clinical, had notcompleted chaperone training. However, staff said theywere prepared and confident in chaperoning.

• Data supplied from the service showed 100% of clinicalstaff had received an appraisal in the 12 monthspreceding inspection. All non-clinical staff had receivedan appraisal.

• Staff had the right skills and training to undertake theMRI scans. This was closely monitored at a corporatelevel and locally by the operations manager. Staff skillswere assessed as part of the InHealth recruitmentprocess, at induction, through probation, and thenongoing as part of staff performance management andthe InHealth appraisal and continuous professionaldevelopment (CPD) process.

• Staff told us InHealth had a comprehensive in-housetraining programme for magnetic resonance imaging(MRI) aimed at developing MRI specific competencefollowing qualification as a radiographer. Modalityspecific training was given in magnetic resonanceimaging safety led by the InHealth magnetic resonancesafety expert and MRI clinical lead that held theinternational magnetic resonance safety officer (MRSO)certificate.

• All radiographers were registered with the Health andCare Professions Council (HCPC) and met HCPCregulatory standards to ensure the delivery of safe andeffective services to patients. Radiographers also had toprovide InHealth with evidence of continuousprofessional development (CPD) at their appraisals.

• Staff had regular one to one meetings with theirmanager and a biannual appraisal to set professionaldevelopment goals. Records we checked confirmed thatstaff appraisals were up to date.

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Diagnostic imaging

Good –––


• All staff were required to complete the InHealthmandatory training programme as well as role specifictraining to support ongoing competency andprofessional development.

Multidisciplinary working

• Staff of different kinds and from differentorganisations worked together as a team to benefitpatients.

• The centre had good relationships with other externalpartners and undertook scans for local NHS providersand private providers of health insurance schemes

• Staff told us there was good communication betweenservices and there were opportunities for them tocontact referrers for advice, support and clarification.

• The registered manager at the centre worked closelywith the InHealth operations manager for theperipatetic services, (these were services that travelledaround InHealth clinics and provided ultrasound,physiological measurement services, echocardiogram,and abdominal aortic aneurysm (AAA) screening), byscheduling clinical room availability for peripateticservices on a monthly basis. The centre also promotedthe availability of peripatetic services in the localcommunity. These services were registered separatelywith the CQC and managed by the registered managerfor the peripatetic services.

Seven-day services

• Appointments were flexible to meet the needs ofpatients, and appointments were available at shortnotice.

• The service operated from 7am to 9pm seven days aweek.

• We were told that a senior manager was available in anon-call capacity out of usual office working hours.

Health promotion

• There was information on diagnostic imagingprocedures available on the InHealth website.

• Information leaflets were provided in the reception areafor patients on what the scan would entail and what wasexpected of them prior to a scan. The service alsoprovided information to patients on self-care following ascan.

• The unit did not enable patients to increase their controlover, and to improve, their health by providinginformation and access to a wide range of social andenvironmental information or health promotingactivities.

Consent and Mental Capacity Act

• Staff understood how and when to assess whethera patient had the capacity to make decisions abouttheir care.

• All staff understood the requirements of the MentalCapacity Act 2005. Staff had recently completed ane-learning course on the Mental Capacity Act. Senior staffconfirmed the training would be updated on a threeyearly basis.

• Where a patient lacked the mental capacity to giveconsent, guidance was available to staff through theInHealth corporate consent policy. We also saw aflowchart to guide staff on the MCA.

• Staff we spoke with understood the need for consentand gave patients the option of withdrawing consent andstopping their scan at any time. The service used consentforms that all patients were required to sign at the time ofbooking in at the service.

• During this inspection there were no patients thatlacked the capacity to make decisions in relation toconsenting to their scan.

Are outpatients and diagnostic imagingservices caring?

Good –––

We rated it as good.

Compassionate care

• Staff treated patients with compassion. Feedbackfrom patients confirmed that staff treated themwell and with kindness.

• During this inspection we saw all staff treating patientswith dignity, kindness, compassion, courtesy andrespect. Staff introduced themselves prior to the start ofa patient’s treatment, interacted well with patients andincluded patients in general conversation.

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Diagnostic imaging

Good –––


• In the interactions we saw during this inspection andfeedback provided by patients we spoke with, staffdemonstrated a kind and caring attitude to patients.Staff explained their role and explained to patients whatwould happen next.

• During this inspection we spoke with four patientsabout various aspects of the care they received atInhealth Ealing. Without exception, feedback wasconsistently positive about staff and the care theydelivered.

• Staff ensured that patients’ privacy and dignity wasmaintained during their time in the centre and duringscanning. Patients had designated changing rooms andwere provided with a gown if required in the changingroom to protect their modesty whilst having their scan.

• To ensure patients were comfortable staff askedpatients if they wanted a blanket for warmth andcomfort before the procedure and we observed staffchecking if patients were comfortable during theprocedure.

• Patient satisfaction was formally measured throughcompletion of the InHealth 'Friends and Family Test’(FFT) following their examination. At the time ofinspection the FFT response rate was 8%. Thepercentage of patients that were extremely likely orlikely to recommend the InHealth Ealing Centre to theirfriends or family was 96%. The InHealth FFT average was99%. Staff told us negative comments were scrutinisedfor opportunities to drive improvement in the servicewhich included changes to premises, staff training orpatient information.

Emotional support

• Staff provided emotional support to patients tominimise their distress.

• Staff supported people through their scans, ensuringthey were well informed and knew what to expect.

• Staff provided reassurance and support for nervous,anxious, and claustrophobic patients. Theydemonstrated a calm and reassuring attitude so as notto increase patients’ anxiety.

• We observed the staff provided ongoing reassurancethroughout the scan, they updated the patient on howlong they had been in the scanner and how long was

left. Patients also had a panic button they could pressany time during the scan to summon help. Staff couldstop the scanning immediately if the patient requestedthis.

• The centre’s staff felt that recognising and providingemotional support to patients was an integral part ofthe work they did. Staff recognised that scan-relatedanxiety could impact on a patient’s scan and this couldresult in possible delays with the patient’s treatment.

• The centre had an up to date chaperone policy. Patientswere asked at the time of booking if a chaperone wasrequired.

• Family members or carers were able to accompanypatients that required support into the scanning area.

• Patients could bring their own choice of music to listento during the scan which was played throughheadphones. This helped to disguise the noise thescanners made which could cause anxiety for somepatients. Earplugs were also available which protectedtheir ears and helped to reduce the noise.

Understanding and involvement of patients andthose close to them

• Staff involved patients and those close to themabout their care and treatment.

• We observed when staff checked through the patient’ssafety questionnaire, patients were given anopportunity to ask questions.

• The service allowed for a parent or family member orcarer to remain with the patient for their scan if this wasnecessary.

• Staff recognised when patients or relatives and carersneeded additional support to help them understandand be involved in their care and treatment. Staffenabled them to access this, including access tointerpreting and translation services.

• Patients and relatives and carers could ask questionsabout their scan. Patients could access information onMRI scanning from the company’s website. However,there was a wide range of information available topatients in the centre.

• Patients were informed of when they would receive theirscan results; there were clear expectations and theservice met their timely goals.

• We saw staff offering an explanation on aftercare to apatient. Staff told us all patients were provided withaftercare advice following a scan.

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Diagnostic imaging

Good –––


• A range of diagnostic and imaging related leaflets wereavailable to patients in the centre. Patients could alsoaccess information on MRI scanning and the differenttypes of diagnostic imaging modalities from theInHealth website. Patients could also request a copy oftheir images on CD from the InHealth patient referralcentre (PRC).

Are outpatients and diagnostic imagingservices responsive?

Good –––

We rated responsive as good because:

Service delivery to meet the needs of local people

• The provider planned and provided services in away that met the needs of local people.

• Information about the needs of the local populationwas used to inform how services were planned anddelivered. The unit provided MRI services throughcontractual agreements with local CCGs. DEXA and X-rayservices operated on Tuesdays 8am to 8pm.

• InHealth Ealing provided an effective community basedGP direct access MRI, X-ray and DXA service to thepopulation of Ealing and surrounding areas throughmultiple clinical commissioning groups.

• Progress in delivering services against the contractualagreement was monitored by the CCGs and privateprovider through key performance indicators, regularcontract review meetings, and measurement of qualityoutcomes including patient experience. Performancewas reviewed and service improvements agreed atthese quarterly meetings.

• The registered manager received a daily informationreport from the patient referral centre (PRC) whichdetailed the centre’s capacity. All patients were offeredan alternative appointment if waiting times in the centreexceeded 30 minutes.

• The extended opening hours of 7am until 9pm, gavepatients a greater choice of appointment times and as aresult had assisted in reduced waiting time forexaminations.

• The service was accessible through established bus andtrain routes. There was a bus stop and a train stationwithin close proximity. Patients were able to use

accessible car parking at the rear of the service. Therewere limited free InHealth parking bays within themultistorey carpark. Patients were required to entervehicle registration details at a monitor in reception toavoid any uneccesary fines. The rear entrance waspredominantly used by disabled patients.

• The facilities and premises were appropriate for theservices that were planned and delivered. There wassufficient comfortable seating, toilets changing roomsand a drinks machine.

• Information was provided to patients in accessibleformats before appointments. Appointment letterscontaining information required by the patient such ascontact details, a map and directions, healthprofessional’s name if appropriate, and informationabout any tests or intervention including if samples orpreparation such as fasting was required. Theappointments letters sent out, asked patients to call ifthey had any queries or if they had answered yes to anyof the questions on the MRI safety questionnaire.

• All appointments were confirmed two days prior topatient’s appointment, by phone. This helped reducethe number of do not attend (DNA's) and also providedan opportunity for the patient to ask us any questionsthey may have. Should a patient not be verballycontacted prior to their appointment, for examplewhere a message is left for the patient on an answermachine, the patient was asked to call the service toconfirm their intention to attend the appointment.

Meeting people’s individual needs

• The service took account of patients’ individualneeds.

• Services were planned to take account of the needs ofdifferent people, for example, on the grounds of age,disability, gender, gender reassignment, pregnancy andmaternity status, race, religion or belief and sexualorientation. Staff had received training in equality anddiversity and had a good understanding of cultural,social and religious needs of the patient anddemonstrated these values in their work.

• Patients with reduced mobility could access thescanning unit as the unit was on the ground floor andcorridors were wide enough to accommodatewheelchairs.There was a rear entrance to the servicefrom the carpark for disabled patients.

Diagnosticimaging

Diagnostic imaging

Good –––


• A MRI compatible wheelchair and trolley were availableshould the patient be unable to mobilise independentlyfrom the waiting area to the MRI room. It wasrecommended where patients required access to ahoist, they were referred to another InHealth service.

• Staff could use a telephone interpreting service forpatients whose first language was not English. We sawthe contact details of the service at the centre’s mainreception.

• The service had arrangements to meet the needs ofthose with sensory impairment. The centre had ahearing loop (a sound system for people with hearingaids). Large print patient information was available andbraille leaflets could be provided on request.

• The service engaged with patients who were vulnerableand took actions to remove barriers when they found ithard to access or use services. For example, patientswho had informed the service that they were nervous,anxious or phobic could be invited to have a lookaround the unit prior to their appointments, so theycould familiarise themselves with the room and thescanner to try to manage their anxieties.

• Staff told us the centre did not provide scanning forpatients weighing over 250 kilograms. All patients withbariatric needs would be identified by the PRC andreferred to the InHealth Croydon diagnostic centrewhich had specialist MRI equipment for bariatricpatients.

• Patients with a learning disability or dementia couldbring a relative or carer to their appointment as support,who could be present in the imaging room if necessary.Parents could also accompany young people over 16where requested. Easy to read leaflets were availableupon request.

• During the MRI scan, staff made patients comfortablewith padding aids, ear plugs and ear defenders toreduce noise. Patients were given an emergency callbuzzer to allow them to communicate with staff shouldthey wish. Microphones were built into the scanner toenable two-way conversation between the radiographerand the patient. Patients could bring in their own musicfor relaxation. A relative or carer could be present in thescan room if necessary and after they have beenscreened for safety.

Access and flow

• InHealth had introduced ‘smart’ booking sessions.These involved staff arranging sessions where specificbody parts where scanned. For example, there had beena session for knee scans. Staff told us this meant morepatients could be seen in the session. Scanningappointment times during these sessions were reducedfrom 20 minutes to 15 minutes.

• Patients were booked by the PRC, which utilisedpre-allocated slots. In the case of requirement toconduct anurgent scan due to a request by a referringclinician or a patient,the PRC offered alternate InHealthlocations to the referrer or patient within a reasonabledistance. This ensured the patient could be scanned inline with their need or that of their referring clinician.Patients requiring urgent X-ray or DXA scans weredirected to a walk-in service in Enfield.

• All referrals were triaged by the radiographers whoreviewed and confirmed suitability of location forpatients to ensure the first time allocated was right forthe patient. For complex cases the clinical radiographicstaff sought assistance from the consultant radiologistteam.

• We viewed the InHealth standard operating procedure(SOP) for MRI triage. This gave triage radiographers atthe PRC a clear framework on which referrals should bebooked at which centres.

• Managers received a daily information report from thebooking centre which detailed capacity and allowed themanager to make an informed decision if waiting timeswere increasing. If required, the manager could extendoperating hours temporarily whilst also reviewing clinicutilisation to reduce lost slots through DNA or rejections.

• From November 2017 to November 2018, 177 of plannedexaminations were cancelled for non-clinical reasons,22 of these were as a result of equipment failure orbreakdown. There were no delayed procedures fornon-clinical reasons in the same period.

• The registered manager told us patients appointmentswould only be cancelled if a machine broke down.Patients that had appointment cancelled would beoffered a scan immediately at another InHealth centreor could re-book their appointment.

• Appointments generally ran to time; reception staffwould advise patients of any delays as they signed in.Staff would keep patients informed of any ongoingdelays through a notice board in the waiting area.

Diagnosticimaging

Diagnostic imaging

Good –––


Learning from complaints and concerns

• The service treated concerns and complaintsseriously, investigated them and learned lessonsfrom the results, and shared these with all staff.

• InHealth had a complaints’ handling policy and all staffcompleted a mandatory training course on complaintsmanagement. The service operated a robust complaintsmanagement procedure which aimed to identify andaddress concerns in a mutually satisfactory manner.

• Patients we spoke with knew how to make a complaintor raise concerns.

• Staff told us they were happy to explain the procedureto patient ensuring the had any contact informationrequired to issue the formal complaint. Advice on howto complain was also available on the provider’swebsite.

• The complaints policy and procedure was displayed forpatients and relatives to read in the main receptionarea. The policy was to acknowledge all complaintswithin three working days and investigate and formallyrespond within 20 working days. There was a three stagecomplaints management policy: stage 1 - localresolution; stage 2 - Internal director review; stage 3 -external independant review. External review would beprovided by either the Public Health ServiceOmbudsman for NHS funded patients or theindependent sector complaints adjucation service(ISCAS) for privately funded patients.

• The service received five complaints and 240compliments between October 2017 and October 2018.All five complaints were dealt with under the formalcomplaints procedure in accordance with the service’stimescales. Of these, three were upheld. Complaintthemes included: patient pathway, reports/results, staffrelated, and communication.

• There were weekly complaints, litigation, incidents andcompliments (CLIC) meetings which reviewed all formalcomplaints and disseminated learning to local teams.

Are outpatients and diagnostic imagingservices well-led?

Good –––

We rated well-led as good.

Leadership

• Managers at all levels in the centre had the rightskills and abilities to run a service.

• Leaders had the skills, knowledge, experience andintegrity needed both, when they were appointed andon an ongoing basis.

• InHealth Ealing was managed by an experiencedregistered manager, supported by regionalmanagement and central InHealth support functions.The registered manager had been with the service sinceFebruary 2018. The registered manager’s line managerwas the InHealth head of operations for London. Theregistered manager attended quarterly regionalmeetings with the head of operations and othermanagers from InHealth’s London diagnostic centres ona quarterly basis.

• The management structure at the centre consisted of aregistered manager supported by a clinical coordinatorand superintendent radiographer. Staff said both theregistered manager, clinical coordinator and the seniorradiographer were approachable, supportive, andeffective in their roles. All the staff we spoke with werepositive about the management of the service. Staff toldus the registered manager was approachable and feltthey could speak without fear of reprisal.

• We viewed a flowchart which clearly documented theInHealth Ealing leadership structure. The head ofoperations for London was directly accountable to thedirector of operations south, who was directlyaccountable to the managing director for diagnosticand integrated services.

• The superintendent radiographer had been employedby InHealth for 11 years at the time of inspection. Theywere positive about the level of support they hadreceived from InHealth. They told us they weresupported by the registered manager withadministration and managerial responsibilities andcould also call the superintendent radiographer atanother InHealth location for peer support and advice.

• Junior and middle managers working for inHealth wereencouraged to gain an NVQ qualification in leadership.There was also a leadership development programmethat would lead to a recognised level 5 qualification forsenior managers in development at the time of thisinspection. The registered manager told us they hadrecently completed a course funded by InHealth inleadership and management.

Diagnosticimaging

Diagnostic imaging

Good –––


Vision and strategy

• The service had a set of clear values that were wellunderstood by staff who were engaged by them.

• InHealth had four clear values: Care, Trust, Passion andFresh thinking. These values were central to all theexaminations and procedures carried out daily.Following the company mission to 'Make HealthcareBetter' enabled all employees to offer a fresh, innovativeapproach to the care delivered.

• All staff were introduced to the InHealth values whenfirst employed during the corporate induction. Theappraisal process was also aligned to the company’svalues and all personal professional developmentobjectives discussed at appraisal were linked to thecompany’s objectives.

• Staff were aware and understood what the vision andvalues were and understood the strategy and their rolein achieving it. All staff were introduced to these corevalues at the cooperate induction and then throughtheir annual appraisal and all personal SMARTobjectives issued at each appraisal were linked to thecompany’s objectives. An objective is a statement whichdescribes what an individual, team or organisation ishoping to achieve. Objectives are 'SMART' if they arespecific, measurable, achievable, realistic and, timely (ortime-bound).

Culture

• Managers at the centre promoted a positive culturethat supported and valued staff, creating a sense ofcommon purpose based on shared values.

• Staff felt respected and valued. Staff told us they feltsupported, respected and valued by the organisation.Staff told us they felt proud to work for the organisation.All staff we spoke with were very happy in their role andstated the service was a good place to work. All stafftalked about the very supportive staff team.

• The service’s culture was centred on the needs andexperience of patients. This attitude was reflected instaff we spoke with on inspection.

• The service promoted equality and diversity, it was partof mandatory training, inclusive, non-discriminatorypractices were promoted.

• A whistle blowing policy, duty of candour policy andappointment of freedom to speak up guardianssupported staff to be open and honest.

• All independent healthcare organisations with NHScontracts worth £200,000 or more are contractuallyobliged to take part in the Workforce Race EqualityStandard (WRES). Providers must collect, report,monitor and publish their WRES data and take actionwhere needed to improve their workforce race equality.A WRES report was produced for this provider in October2018 including data from September 2017 to September2018. There was clear ownership of the WRES reportwithin the provider management and governancearrangements, this included the WRES action planreported to and considered by the board.

• There was a system in place to ensure non-NHS-fundedpeople using the service were provided with astatement that included terms and conditions of theservices being provided to the person and the amountand method of payment of fees.

Governance

• The provider used a systematic approach toimproving the quality of its services andsafeguarding high standards of care.

• There was an effective governance framework tosupport the delivery of the strategy and good qualitycare. The service undertook a number of quality audits,information from these assisted in driving improvementand giving all staff ownership of things which had gonewell and action plans identified how to address thingswhich needed to be improved.

• InHealth operated a comprehensive clinical governanceframework which aimed to assure the quality of servicesprovided. Quality monitoring was the responsibility ofthe location registered manager and was supportedthrough the InHealth clinical quality team through theframework and governance committee structure. Thisincluded a quarterly risk and governance committee,clinical quality sub-committee, medicines managementgroup, water safety group, radiation protection group,radiology reporting group and a weekly meeting forreview of incidents and identification of shared learning.

• Local governance processes were achieved throughmonthly team meetings and local analysis ofperformance, discussion of local incidents. Feedbackand actions were fed into processes at a corporate level.We saw evidence of this process in meeting minutes andmeeting notes during our inspection.

Diagnosticimaging

Diagnostic imaging

Good –––


• Staff were clear about their roles and understood whatthey were accountable for. All clinical staff wereprofessionally accountable for the service and care thatwas delivered within the unit.

• Staff working with radiation were provided withappropriate training in the regulations, radiation risks,and use of radiation. Staff were aware of the changesmade by the introduction of the Ionising RadiationRegulations 2017 (IRR17) and the Ionising Radiation(Medical Exposure) Regulations 2017 (IRMER17) whichhad been introduced in February 2018.

• Service leads had received training in their area ofspecialisms. For example. the registered manager actedas the centre’s lead for safeguarding.

Managing risks, issues and performance

• The service had effective systems for identifyingrisks, planning to eliminate or reduce them, andcoping with both the expected and unexpected.

• Performance was monitored on a local and corporatelevel. Performance dashboards and reports wereproduced which enabled comparisons andbenchmarking against other services. Information onturnaround times, ‘did not attend rates’, patientengagement scores, incidents, complaints, mandatorytraining levels amongst others were charted.

• There was a comprehensive business continuity plandetailing mitigation plans in the event of unexpectedstaff shortages or equipment breakdown.

• InHealth were working towards accreditation with theImaging Services Accreditation Scheme (ISAS) and wereusing the traffic light system tool and gap analysis toprepare for ISAS inspection. The director of clinicalquality was leading on the accreditation preparation. Aspart of this InHealth were working on the developmentof evidence for each of the domains including:leadership and management, workforce, resources,equipment, patient experience and safety. The directorof clinical quality and clinical governance lead weremembers of the ISAS London Region Network Groupwhich shared best practice and guidance on servicesworking towards accreditation. InHealth aimed to beaccredited across diagnostic and imaging services by2020.

• Weekly complaints, litigation, incidents andcompliments (CLIC) meetings and InHealth biannual

safeguarding board’s monitored compliance withsafeguarding policies and raising concerns processes.The boards identified themes from incidents and setimprovement goals.

Managing information

• Electronic patient records were kept secure to preventunauthorised access to data, however authorised staffdemonstrated they could be easily accessed whenrequired.

• Staff had access to InHealth policies and resourcematerial through the InHealth computer system.

• There were sufficient computers available to enablestaff to access the system when they needed to and themanager had a laptop computer.

• Staff were able to locate and access relevant and keyrecords easily, this enabled them to carry out their dayto day roles

• Information from scans could be reviewed remotely byauthorised referrers to give timely advice andinterpretation of results to determine appropriatepatient care.

• Key performance indicator data was monitored centrallyby the provider to ensure the centre were meeting theprovider’s standards of care.

• As part of the InHealth contract, staff had access to anNHS portal. Staff could request access to previouspatient images and could add images to NHS patientrecords. This ensured NHS patients received continuityof care in imaging.

Engagement

• The service engaged well with patients, staff, thepublic and local organisations to plan and manageappropriate services, and collaborated withpartner organisations effectively.

• Patients’ views and experiences were gathered andacted on to shape and improve the services and culture.Patient surveys were in use, the questions weresufficiently open ended to allow people to expressthemselves. We saw changes were implementedfollowing feedback from patients.

• In October 2018, the service extended the opening hoursto increase patient’s choice to have an appointmentoutside of the standard working hours.

• InHealth Ealing identified a trend of patients mistakingInHealth Ealing for Ealing hospital. To action this theservice altered the appointment letter to make clear the

Diagnosticimaging

Diagnostic imaging

Good –––


service was not Ealing Hospital. In response to patientsadvising of a local bus route change, appointmentletters were edited appropriately to reflect the change intransport options.

• Staff told us they felt actively engaged. Their views werereflected in the planning and delivery of services and inshaping the culture. Annual staff satisfaction surveyswere undertaken. These were used to seek views of allemployees within the organisation and actionsimplemented from the feedback received.

• The service consistently reviewed X-ray and DXA waittimes with the PRC to determine if additional clinicswere required to reduce wait times.

• The service engaged regularly with clinicalcommissioners at monthly meetings to understand theservice they required and how services could beimproved. This produced an effective pathway forpatients. The service also had a good relationship withlocal NHS providers.

• Feedback from the friends and family test (FFT) wasanalysed by an external, independent company and theresults and a dashboard sent to the clinical qualityteam. Data was provided on number of items includingpatient satisfaction percentage and all comments wererecorded. These were available weekly on the InHealthintranet.

• Staff told us InHealth had a service user group that hadbeen involved in the formulation of the company’svalues.

• Formal minuted team meetings were held on aquarterly basis. The registered manager told us therewere weekly informal site meetings to discuss day today working plans and schedules.

• An employee wellbeing and assistance programme wasavailable to staff to support them during times of crisisand ill-health.

Learning, continuous improvement and innovation

• InHealth had a corporate strategy, this included anexpansion programme whereby the provider wouldprovide three million diagnostic imaging appointmentsfor the NHS in 500 locations by 2020.

• InHealth were working towards accreditation with theImaging Services Accreditation Scheme (ISAS). Thedirector of clinical quality and clinical governance leadwere members of the ISAS London Region NetworkGroup which shares best practice and guidance onservices working towards accreditation. InHealth aimedto be accredited across diagnostic and imaging servicesby 2020.

• Since February 2018, the clinical team had beenadditionally trained to support the InHealth wideremote triage function for the business. Radiographerswere allocated protected time to review referrals toensure they were adequately completed and clinicallyjustified. They assessed any highlighted MRI safetyissues and contraindications in advance of booking andthese steps to ensure the patient receives the correctappointment first time.

Diagnosticimaging

Diagnostic imaging

Good –––


Areas for improvement

Action the provider SHOULD take to improve

• The provider should introduce chaperone training forall staff members.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Enforcement actionsEnforcementactions


InHealth Ealing NewApproachFocused Report … · 2019-08-02 · Efficiency models from...

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