PETCT Mobile Services

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all of the quality statements from safe, responsive and well-led key questions and found areas of good practice. The assessment of these five quality statements showed an overall rating of good. SAFE We reviewed the learning culture, safe systems, pathways and transitions safeguarding, involving people to manage risks, safe environment, safe and effective staffing, infection prevention and control and medicines optimisation. Learning Culture: The service provided safe care and treatment based on national guidance and best practice. There was evidence that the service learned from incidents. Safe systems, pathways and transitions: The service had processes to safely transfer patient records to partnership agencies. Safeguarding: Staff received training on how to recognise and report abuse and they knew how to apply it. Involving people to manage risks: The service provided information about the type of imaging they offered including the side effects of radiation. This enabled people to make decisions about their care and treatment. Safe environment: Staff carried out daily safety checks of specialist equipment to ensure it was in good working order. The service had suitable facilities and equipment to safely meet the needs of patients. Safe and effective staffing: The service had enough staff to provide safe care and treatment. Infection prevention and control: We saw staff followed guidance on IPC and PPE. Medicines optimisation: Medicines were well managed.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not collect enough evidence from patients about this quality statement to express their views in this report.

Staff at all levels told us they worked in a learning rather than blame culture, which they said encouraged them to report and learn from incidents. The provider had received accreditation from a national organisation that recognised they learned from incidents. Staff mostly reported incidents and near misses in line with the provider’s policies and procedures. Senior leaders told us about an incident of a patient receiving above justified doses of radiation that was not identified by the radiographer at the time, but was picked up through a random dose audit. Once detected the incident was immediately entered onto the providers electronic incident system. However, we saw an incident when a patient had received above justified levels of radiation that had not been reported on the incident system but had been reported to an external medical physics team. The medical physics team notified senior leaders, but this incident was not reported on the providers electronic incident system for 1 month. This delay in reporting was identified as a learning point and staff were provided with additional training to ensure a consistent approach to reporting incidents. Staff told us they were given time to complete required learning. This included regular development days held at the head office. Staff understood how to apply the duty of candour and they knew the system to follow to do this. They would inform the radiation protection supervisor in the first instance and then offer a full apology to the patient with an explanation of what went wrong and why.

The service provided mandatory training in key skills to all staff and made sure everyone completed it. Overall compliance with mandatory training in June 2024 was 98% and the provider sent evidence to show most of the training that had not be completed was by new employees. The service managed patient safety incidents well. There were processes in place for staff to follow when reporting incidents, including reporting to external bodies. Incidents were discussed as part of regular meetings, and where learning was required, there were processes to follow for staff to ensure this was shared and embedded. From July 2023 to June 2024 a total of 334 incidents were reported. Twenty-eight incidents were reported as near misses and 152 that caused no harm. Radiation protection was the highest reported incident category, this included patient radiation incidents and staff dose incidents. Of 126 reported radiation incidents, 40 were related to staff doses, 10 were relating to non or late return of dose monitoring equipment, 3 related to contamination due to patient incontinence and 5 related to radiation spills. During the timeframe 9 incidents related to patients who were unwell and required medical attention, of these 4 patients required transfer to the accident and emergency department. This is a rate of 0.09 incidents per 1000 scan patients requiring transfer. There were 4 CQC reportable incidents across the time period. The Administration of Radioactive Substances Advisory Committee (ARSAC) attended regular learning meetings for their substantive trusts where they looked at exceptions and clinical incidents. The outcome of this learning was shared with staff. An ARSAC is the person who holds the license at a location to use radioactive substance on people. Managers ensured that actions from patient safety alerts were implemented and monitored.

The patients we spoke to told us they did not have any concerns about the transfer of their information between the provider and their partnership organisations.

Staff made sure each patient had a complete electronic patient record. Anything that had been completed on paper, for example, the signed patient consent form, was scanned and uploaded into individual’s electronic records. All the information from the scan, including the position of the patient, was recorded to augment the scan images. Each patient record was sent to a radiologist to be reported on. Sometimes trusts provided the reporting radiologists, at other times the service used their own team of radiologists to report on the scan. Once reporting was complete the referring doctor would be sent the scan results through the picture archiving and communication system (PACS). The process of completing and reporting on the scan was done within 7 days. If the PACS connection was interrupted the provider could also send scan images by encrypted USB or encrypted CD to ensure the 7-day timeframe was met. Staff told us they wore dose meters so they were continually being monitored for the cumulative amount of radiation they had been exposed to. This information was sent to senior leaders so they could ensure staff were not exposed to above safe levels. Leaders told us if dose levels were unusually high, they would investigate this. The investigation might include, for example, a review of handling the radioactive tracer. Staff received an annual occupational health review which included a review of dose exposure to ensure staff had not reached annual dose limits. Two spare dose meters were kept on each unit so carers or other visitors could have their expose levels monitored. Any cases of above safe levels of expose were reported as an incident.

We were told trusts and the provider worked closely together to provide high quality safe services. Partners mostly told us when things go wrong there was openness and collective learning. Three of the 5 responses we received from partnership NHS trusts said the provider’s staff did not consistently stick to agreed local scan protocols. Scan protocols were set to ensure patients were only exposed to the amount of radiation justified by the ARSAC. However, the responses also said patients had not come to any harm. One partner reported when the mobile unit was moved before all the scan images had been transferred to the trust for reporting this could result in delays, caused by the provider needing to upload the images to an encrypted CD and couriered back to the trust. Another partner reported scan protocols had not been standardised across the providers mobile fleet leading to some failed scans. We also received feedback to say that some issues with patient reconstruction were only picked up by the trust and not detected by staff at the mobile location. Reconstruction refers to the process of combining PET and CT images to show distribution of the radiotracer in patients to locate cells with high levels of activity. Feedback from partners also demonstrated that the use of different patient record systems means if a patient required additional scans at an NHS site, the NHS staff might not be able to access the providers original scan image and report leading to delays in patient treatment.

The process for sharing patient information to ensure continuity of care was governed by the commissioning agreements between the different trusts and provider. There were systems for ensuring the unit, including the scanners, were ready with everything working correctly at the start of each day. There was a process for staff to follow if the scanner stopped working this included the trust being asked to provide mutual aid and complete the scan of the patients especially if they had already received their radiotracer. If this was not an option, patients would be transferred to 1 of the provider’s static sites. If this was also not an option, the patient would be rebooked based on their clinical need. Each mobile unit had 1 or 2 spare slots each day to ensure patients had an opportunity to be seen later the same day or the following day in such cases.

We did not collect enough evidence from patients about this quality statement to express their views in this report.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and work with other agencies to protect them. Staff knew how to make a safeguarding referral, and who to inform if they had concerns. Staff told us in the first instance they would discuss their concerns with a manager. The provider had a safeguarding lead based at the head office who could be contacted for advice. There was also a lead for PET-CT mobile services and area managers who could be contacted for advice throughout the working day. There was a site file for each location which contained details of the local safeguarding teams, so staff knew what to do and who to contact if they needed to make a referral.

The service had a safeguarding adults policy and a safeguarding children policy. The policies contained flow charts that gave staff step by step guidance of what to do if they had a safeguarding concern. Each mobile unit had a local file that included the details of safeguarding teams. The national safeguarding lead was based at head office and was available to offer advice and support to mobile teams. Staff received training specific for their role on how to recognise and report abuse. Data provided to us following our assessment showed compliance with safeguarding training was 96%. Managers received training up to level 3 and the organisation had a level 4 trained safeguarding lead.

Patients told us they had been given information so they knew what to expect during their scan, this included information about the risks of radiation. They said they had been emailed written information about the side effects of radiation after their appointment was booked. They were also given verbal information before being injected with the radiotracer, including instructions to avoid children and pregnant women for 6 hours after their scan. There were posters for patients in the uptake rooms about pregnancy and offering patients the opportunity to have a chaperone. Patients had to sit or lie in the take up rooms for 1 hour before their scan. There were notices to let patients know that they were being monitored by a live feed CCTV. Patients fed back to the provider they felt they were given the right amount of information at the right time. The provider worked hard to ensure the right balance of information was given to patients to stop them being overwhelmed with vast amounts of information about the complexity of the procedure.

Each site had an ARSAC who was a radiologist substantively employed by the trust each mobile unit was based at. The ARSACs were also employed by the provider to offer onsite support to the mobile teams during their operational hours. Part of the ARSAC’s role was to vet referrals in line with Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R). Staff used local protocols to cover their practice, these contained clear instructions which were easy to understand. Staff followed the Society of Radiographers ‘pause and check’ guidance when checking patient’s identity before administering injections or scanning patients. The service ensured staff were aware of patients who were or may be pregnant, in accordance with IR(ME)R, and Ionising Radiation Regulations (IRR) 2017. We saw posters displayed in patient areas asking patients to speak to a member of staff before they were scanned if they may be pregnant. The service ensured that the radiation protection advisor and the medical physics expert were easily accessible to staff requiring radiation advice. Audits on the amount of radiation patients received from scanners were completed by the trusts and the provider. Results from the provider and trust were shared. Staff told us learning from these audits had resulted in a dose limiter being put on all scanners to reduce the likelihood of patients receiving higher than justified amounts of radiation. Staff told us they received regular information about complaints, incidents and near misses at meetings and this was also sent to them via email.

The service had an Ionising Radiation (Medical Exposure) Regulations 2017 procedures policy. It included the request criteria, providing benefit and radiation risk information to patients, exposure charts, reporting of radiological images, use of equipment, and how to contact the radiation protection advisor and the medical physics expert. Regular radiation protection audits were carried out to assess local compliance with the Ionising Radiation regulation 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017. All requests for imaging were entered onto the radiology information system. The ARSAC ensured imaging requests were appropriate and included the relevant information to allow for requests to be justified in accordance with Ionising Radiation (Medical Exposures) Regulations (IR(ME)R). The patient request forms we reviewed contained the required information including patients’ medical history, and the clinical indication for the scan. Each location had a standard operating policy (SOP) to cover radiation exposure to carers and comforters that met the Ionising Radiation (Medical Exposure) Regulations 2017. The radiation exposure to carers and comforters was classed as a medical exposure and therefore had to be justified to keep radiation doses as low as possible. The SOP gave clear instructions to staff that the risks and benefits of exposure must be properly explained to carers and comforters. Individuals were required to give written consent to being exposed to radiation in their role as carer or comforter and the level of radiation they received was recorded within the patient’s notes. Each morning the team had a safety huddle. One of the agenda items was to allocate staff their role in the event of a cardiac arrest. For example, who would call the resuscitation team, and who would commence cardio pulmonary resuscitation. This meant staff would understand their role in case of emergency.

Patients told us they thought the scanning units provided a safe environment. One patient said they felt unsteady walking up the stairs to enter the mobile unit. However, they also said staff offered them support to climb the stairs.

Each mobile site had a ‘hot toilet’ based in 1 of the trust buildings. A hot toilet is used for people who have been given a radiotracer and whose urine would be mildly radioactive following their procedure. The ARSACs held Environmental Agency permits that covered safe disposal of this waste. Staff told us they carried out daily safety checks of specialist equipment including the scanners. The CT equipment was not useable until a safety check (calibration) had been performed at the start of each day. A CCTV live feed of patients in the uptakes rooms was displayed at the control desk. This ensured staff could see patients were fit and well throughout the duration of the wait from the radiotracer being injected until they were taken through to the scanner room. The team had received training on trouble shooting problems with the scanners, this meant they were sometimes able to fix problems without calling out an engineer. Staff told us that when equipment was found to be broken they labelled it as faulty and logged this with the estates team.

Patients had to walk up a short flight of stairs to enter the mobile units. The stairs were securely attached to the unit. If patients used a wheelchair, or if they felt unable to use the stairs, they could access the unit through a lift on the front of the unit that gave direct access into the control room. Spill kits were kept on the units to safely mop up accidental spillage of the radiotracer. Although spillage was most likely to occur in the hot lab or uptake rooms the spillage kits were stored in the scan room. This was because of the compact design of the unit and the lack of storage space in some areas. Staff used PPE to keep themselves safe while injecting the radioactive tracer. The tracer was delivered in a lead lined box and stored in a locked lead lined cupboard in the hot lab while it was not being used. The environment was visibly clean. Resuscitation equipment was readily available, adequately stocked and there was evidence of regular review. The resuscitation equipment we saw was clean and in good condition. We saw the facilities and equipment were well maintained and used for intended purpose and used properly. All equipment we checked had an up-to-date electrical safety check. Staff disposed of clinical waste safely in a secure radioactive waste safe. Once in the safe the content was the responsibility of the ARSAC and disposal was managed by each trust. The sharps disposal safe at the City Hospital location had a hazardous waste sign on the side of the safe. We recommended this signage should be improved and the provider showed us evidence to demonstrate a radioactive waste sign had been affixed to the front or the safe. There was enough radiation signage and lights to show when scans were in progress. This helped keep staff and patients safe from exposure to radiation. We saw health and safety posters in the control room that contained contact details of the providers health and safety team.

There were systems to check the image quality of scans this included daily and weekly quality assurance checks and a process for staff to follow if image quality was below standard. Monthly audits were completed centrally on image quality. Incidents detected through the quality assurance processed were discussed at Radiation Protection Supervisor (RPS) meetings to share learning and improve quality. There were processes to ensure staff completed daily checks of the integrity of the mobile unit as well as performing daily quality assurance checks of the scan equipment. All checks were documented so the outcomes could be audited.

The service had enough staff to keep patients safe. Patients told us they thought the ratio of staff to patients was good.

Staff completed a range of mandatory training modules. They received an automatic notification if they had training that was due to go out of date. Staff told us if they had not completed their mandatory training, they were unable to book shifts until the training was completed. The service had a nine percent turn over this was down from 22% four years previously. Senior leaders were pleased with their retention figure and at the time of our inspection the vacancy rate was 3.19% this represented one vacancy for a clinical assistant. The was a minimum of 3 staff at each mobile unit, 2 radiographers/technologists and a clinical assistant. Staff were supported offsite by leads based at the head office and peripatetic area managers and a service lead. Each unit typically had a RPS on site, this was the technologist or radiographer. The RPS is qualified to supervise the ionising radiation work in compliance with the local rules. An RPS and a Radiation Protection Advisor (RPA) were available at the head office and a Medical Physics Expert (MPE), contracted through an external service, were available at all times to provide remote support to the mobile workforce. A monthly RPS meeting was held at the head office. Staff were supported with travel and expenditure related to overnight accommodation to ensure attendance. The meetings were used to share information as well as provide a forum for development. Clinical assistants attended a similar quarterly meeting.

The provider used safer staffing processes to recruit staff. We looked at 5 staff files and saw they all had an up-to-date Disclosure and Barring Service (DBS) check, evidence of qualifications, references to support their last three years of employment, and a full employment history. We saw the electronic system used to allocate staff to shifts. The system gave staff the opportunity to request some specific shifts. It was also used to fill vacant shifts created through staff absence.

The mandatory training the service provided was comprehensive and met the needs of patients and staff. Staff had completed and kept up to date with their mandatory training. The system used for booking shifts meant only staff with the right skill level could be booked onto a shift that matched the skill set required. The process used to allocate staff to shifts meant staff who were not up to date with essential training, for example, Immediate Life Support training, were automatically excluded from being offered shifts until their training had been completed. The shift allocation process also limited staff from working more hours than laid out in the European working time directive, or more than 5 days without a break of at least 48 hours. New PET-CT staff were initially trained in a static PET-CT site. They then received additional training on a mobile unit. New members of staff were supernumerary for between 4 and 6 months while they completed their work place competencies. Training for internationally recruited staff ensured their competencies aligned with UK standards. Learning events held as part of the monthly technologists meeting were recoded so staff across the organisation had access to this information. The provider had recently organised training for radiographers from the manufacturers the of the PET-CT scanning devices to increased staff knowledge and skills to troubleshoot problems with the scanners and log faults they could not mend with the service team. The provider had introduced specific training on recognising and responding to patients with learning disabilities and autism in line with national guidance introduced in July 2023. Compliance with appraisals was 100%.

Patients told us the mobile units were visibly clean. They said staff used PPE appropriately.

A deep clean of each mobile unit was performed once a month by an external agency. Staff told us they cleaned the unit and equipment in between patients.

All areas of the mobile units were visibly clean and had suitable furnishings which were clean and well-maintained. We saw staff disinfect the chairs in the take up rooms and the scanner bed after each patient. We observed staff washing their hands, in the portable sink, in between patients. We saw staff wearing PPE when drawing up and administering radiotracer.

Staff performed a monthly IPC audit on each mobile unit. We were shown audit results for the 12 months before our inspection. Two issues had been raised during that timeframe (low stocks of PPE and a sharps item not disposed of in a sharps bin), and immediate action had been taken to resolve the problems. Leaders performed an additional annual IPC audit on each mobile unit. We looked at the results for 2 units, they scored 97% and 98%. We saw areas for improvement were identified. Staff complete monthly peripheral vascular device insertion (cannulation) and hand hygiene audits. The handwashing audits that took place between September 2023 and July 2024 showed staff were 100% compliant with correct handwashing techniques.

Patients told us they did not have any concerns about the storage or safety of medicines used during their procedure.

Prefilled saline syringes were used to flush the injection site. These syringes are classed as a medical devices rather than a medicine. This meant the only medicines stored on site were the radioactive tracer fluorodeoxyglucose (FDG). All mobile units had an automatic dosing/dispending system. This reduced the amount of handling of FDG and therefore reduced radiation exposure to staff.

We saw deliveries of FDG. This medicine arrived in a lead lined box that required a serial number to unlock it. The serial number was different for each delivery. Staff moved the FDG to the hot lab as soon as possible. We saw patients being asked about their allergies as part of the booking in process. Emergency medicines were available in the event of an anaphylactic reaction to FDG. Patients were given post scan information which included details of the medicine they had been given. It advised patients to seek advice from their GP or accident and emergency department if they felt unwell after leaving the unit and explained they should tell healthcare professional they had been a recipient of FDG.

The ARSAC at each site ensured that the Medicines (Administration of Radioactive Substances) Regulations 1978 were followed. The ARSAC, or their delegate, was available by telephone or face to face to support staff throughout the day. Contact details for the ARSAC were kept in the site file for easy access. The tracer was made off site and delivered to each unit across the course of the day. Because FDG does not stay radioactive for long, fresh batches of the medicine needed to be delivered in line with the number of patients being scanned in any 1 day. The were processes for the storage and management of FDG, including the measurement of the level of radioactivity of the dose of FDG being administered. Medicines were stored securely in the hot lab at the correct temperature, in line with the manufacturer’s recommendations. Staff had specific training on the safe administration of intravenous FDG. At our last inspection in 2019 we were concerned that the dose of FDG was not checked by a second clinician prior to administration. However, as only 1 medicine/radiotracer was used for patients accessing mobile units, which was dispensed through an automated process the provider deemed this process safe. The provider felt that by exposing a second member of staff to radioactivity was a less safe option.