Background to this inspection
Updated
31 January 2020
Leeds PET-CT Centre is operated by Alliance Medical Limited. (AML) The Leeds PET-CT Centre comprised of a purpose-built facility within the nuclear medicine department of the Bexley Wing, St James University Hospital, Leeds.
The service opened in May 2010 and this is a NHS service provided by an independent sector provider. The service was commissioned by five clinical commissioning groups and primarily served the communities of the West Yorkshire and Vale of York regions scanning patients of all ages.
The centre operated under the NHS England national PET contract and had two PET-CT scanners on site which operate from Monday to Saturday 0730 - 1930. Saturday opening may also take place if referral volumes are high. The service also operated a two day turn around scan reporting time.
The service had a registered manager in post since January 2011.
Updated
31 January 2020
Leeds PET-CT Centre is operated by Alliance Medical Limited. The service is based in a purpose-built facility within the nuclear medicine department of the Bexley Wing, St James University Hospital, Leeds.
PET-CT was a directly commissioned service within NHS England. The service has a service level agreement in place with the NHS Trust to deliver positron emission tomography (PET) scanning services to West Yorkshire via NHS England and Leeds Teaching Hospitals Trust, taking referrals for some specialist scans from as far away as Scarborough. Adult and children attend the centre; however, only NHS based staff undertook scans on children.
Positron emission tomography–computed tomography, is known as PET-CT. This nuclear medicine technique combined, in a single gantry, a PET scanner and an x-ray computed tomography (CT) scanner. Sequential images were obtained from both devices in the same session, which were combined into a single superposed image. The scan used a special dye containing radioactive tracers. These tracers were injected into a vein in the arm dependant on what part of the body was being examined.
Service facilities included two hot labs, two scanning rooms, a control room, five injection rooms, a changing room and two hot toilets.
We inspected this service using our comprehensive inspection methodology and carried out an unannounced inspection on 4 December 2019. We also completed staff and patient telephone interviews on the 9 and 11 December 2019.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, 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 complied with the Mental Capacity Act 2005.
Services we rate
We rated the service as Good overall.
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Managers had the right skills and abilities to run the service and staff described a positive culture where managers, staff and the multi-disciplinary team worked well together. The service ensured staff were competent with the right qualifications, skills and experience to keep people safe from avoidable harm and to provide the right care and treatment. Managers appraised staff’s work performance as a means of development.
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Staff cared for patients with compassion, provided emotional support to minimise their distress and involved patients and those close to them in decisions about their care and treatment. Feedback from patients confirmed that staff treated them well and with kindness.
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Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Policies and procedures were implemented when a patient could not give consent.
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The service systematically improved service quality and safeguarded high standards of care. Patient safety incidents were well managed, and staff recognised incidents and reported them appropriately. Staff of different kinds worked together as a team to benefit patients.
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The service had suitable premises and equipment and looked after them well.
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The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
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The service planned and provided services that met and took account of the individual needs of local people. Care and treatment was based on national guidance and evidence of its effectiveness and managers checked that staff followed this guidance. Patients could access the service when they needed it, appointments were prioritised, and additional sessions had been put in place so that patients scans could take place in a timely way. Waiting times from referral to scan were in line with good practice.
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The service treated concerns and complaints seriously, investigated them, learned lessons from the results, and shared these with all staff.
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The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
However, we also found the following issues that the service provider needs to improve:
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None of the four eligible staff had completed level two children’s safeguarding training.
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Daily resuscitation equipment checks did not always take place as identified by Alliance Medical Limited.
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Planned maintenance of the defibrillator did not always take place.
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The corporate business continuity plan was out of date.
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Patients did not always sign and date their agreement in relation to the use of their images as a teaching aid.
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Staff did not know how to access service specific information.
Following this inspection, we told the provider that it should and must make improvements, to help the service improve. Details are at the end of the report.
Ann Ford,
Deputy Chief Inspector of Hospitals (North)
Updated
31 January 2020
We rated this service as good overall with ratings of good for caring, responsive and well led. Requires improvement for safe. CQC does not rate effective for diagnostic imaging services. There were areas of good practice, and areas identified where the service should and must improve.