People we spoke with were very complimentary about the services they received at Lady Mc Adden Breast Screening Unit. People told us that staff were 'caring' and 'compassionate'. People said that the screening procedures were explained to them fully and they were provided with written information about mammography and ultrasound scans.

We found that people's consent to their treatments were obtained and recorded. Treatments and the advice given to people were recorded in their notes. Mammogram films were checked for accuracy and detail and where results indicated the need for further screening or treatment people and their doctors were informed promptly.

We saw that premises were well maintained, clean and fit for purpose. There were effective arrangements for cleaning and minimising the risks of infection.

There was a robust system in place for recruiting new staff and appropriate checks were carried out in line with current legislation.

We found that the service was well led, monitored and managed safely. People's views were sought and taken into account in how the service was run.

We spoke with three people who told us the staff spent time talking to them about all aspects of the scanning process before it begins. They told us that each step of the scan process and time frame to receive results were clearly explained. People also told us that they felt they could ask questions if they wanted to. People said staff were always kind, supportive and friendly. We noted that there was information in the reception area for people to provide feedback about the service at any time.

The service had clear pathways in place for people receiving a scan. People were provided with clear information on scan types and examination prior to commencement of the process. This meant that people understood all aspects of their treatment.

We found that the service had clear processes in place to cooperate with other providers. The process for referral into other services for treatment of acute breast disease was clear and staff had a good knowledge of this.

The service had a clear quality assurance process in place to ensure people received the best care. The service had a complaints policy in place and people were invited to provide feedback on the service. During our inspection no concerns were raised by people we spoke with.

Lady McAdden Breast Screening Unit is operated by Lady McAdden Breast Screening Trust. The service offers routine screening by mammography, consultation for clinical examination and breast awareness and osteoporosis clinics run at a location nearby. The service has one mammography x-ray room, two clinical rooms, waiting areas and administration areas.

The service offers routine mammography (aged 40 years and over), ultrasound examination, breast examination and awareness advice and osteoporosis clinics for patients aged 18 years and over. Patients self-refer to the service which is funded solely by charitable donations.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 12 December 2018, with a further visit to the service on 7 January 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.

The main service provided by this hospital was routine mammography screening using diagnostic imaging equipment (x-ray).

Services we rate

Our rating of this service was Good overall.

We found the following areas of good practice:

• Staff understood how to protect vulnerable patients from abuse.

• Diagnostic imaging equipment had been regularly maintained in line with manufacturers recommendations.

• The service controlled infection risk well. Staff kept themselves, equipment and premises clean. Control measures were in place to prevent and control the spread of infection.

• The service had enough staff.

• Medical records were complete, contemporaneous, well organised and secure.

• Staff of different kinds worked together as a team to benefit patients.

• Staff cared for patients with compassion and provided support to minimise distress.

• Staff involved patients and those close to them in decisions about their care.

• The service planned and provided services to meet the needs of local people whilst mostly taking account of individual need.

• Patients could access the service in a timely manner.

• The service treated concerns and complaints seriously and sought patient feedback through a variety of methods.

• The service had a clear mission statement in place with workable plans to turn it in to action.

• Managers across the service promoted a positive culture that supported and valued staff.

• The service engaged well with patients, staff and the public.

• Staff offered a bespoke service and were committed to improving services by forward planning the future delivery of breast awareness education and mammography to self-referring patients.

We found the following areas the service needs to improve:

• We could not gain assurances that staff directly employed by the service had completed mandatory training at recommended intervals.

• Protocols did not contain reference to national guidance.

• We were unable to gain assurances that the service managed incidents (including those relating to patient safety) in an effective manner. There was no incident reporting policy in place.

• The service had limited systems in place to identify, monitor and regularly review risk.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected diagnostic and screening services. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals