University of Derby Clinical Services is operated by University of Derby. The service has a reception area, separate waiting area and a clinical room containing the dual-energy x-ray absorptiometry machine.

The only service provided by this university was diagnostic imaging, more specifically dual-energy x-ray absorptiometry (DEXA) scanning. We therefore only inspected diagnostic imaging services at this location.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced visit to the service on 11 December 2018. Due to no clinical activity taking place during this unannounced visit, we completed an announced visit to the service on 18 December 2018.

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 previously did not have the authority to rate this type of service, however now we do. We rated it as Good overall, but Requires Improvement for well-led.

We found the following areas of good practice:

• There was a system and process in place for identifying and reporting potential abuse. Staff were supported by individuals with more enhanced training in safeguarding and there were clear channels of escalation which staff were aware of.

• Clinical environments were visibly clean and tidy, and were suitable and appropriate to meet the needs of the patients who attended for appointments.

• The scanning environment had appropriate signage in place and staff conducted and recorded regular quality checks of the equipment. There were local rules in place for staff to follow which were written by a suitably qualified radiation protection advisor.

• Staff conducting the scans had evidence of appropriate, in date radiation safety training.

• There was a process in place for escalating unexpected and significant findings and staff were able to provide examples of when they had followed this.

• Feedback from patients and their relatives was positive and we observed some examples of compassionate care.

• There was evidence of staff working well with multidisciplinary team members both internally and externally, with staff commenting on the good working relationships they had formulated.

• The service reported low numbers of did not attend appointments and had a process in place for following up patients who failed to attend their appointments.

• Managers were supportive and visible and staff were confident to approach them if they had concerns to escalate.

• There was a process in place to identify, assess and manage risks to the service.

However, we also found areas of practice the service needed to improve:

• During our initial inspection, staff were only mandated to complete regular training on child and adult protection and basic life support. Additional training including infection prevention and control and manual handling was completed as continuing professional development of the practitioner and not recorded by the provider. However, since our inspection the provider has informed us they intend to review the mandatory training requirements of all staff and update any supporting policies for this.

• The service had not recently conducted any quality assurance audits of the scan reports they were producing. However, information provided following the inspection provided robust actions of how they intended to address this.

• There was no infection prevention and control policy in place at the service to enable staff to adhere to correct principles and standards. We observed staff not always being bare below the elbow when providing care and treatment, although direct (hands on) patient care was minimal.

• There were governance systems in place to monitor the quality and sustainable care being provided to patients, however these had failed to identify when audits had not been conducted and when policies and procedures had not been updated to include new regulations, legislation or best practice.

• There was no system in place to provide translation and interpretation services for patients who did not speak English as their first language.

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 for the service to address. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central)