Nuffield Health Brentwood Hospital

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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

At our last assessment we rated this key question as outstanding, but it was combined with the outpatient’s department and was under a different methodology. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

Patient areas were safe, visibly clean and well equipped, well maintained and fit for purpose. The service demonstrated a learning culture although there were some shortfalls for safe systems, pathways and transitions in care.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice although these were not aways fed back to individual staff.

People were able to raise concerns and report incidents. The service had systems for recording safety incidents using an electronic incident reporting tool. Concerns and incident reports were taken seriously, investigated and learning shared with colleagues. Between January 2025 and June 2025 staff reported 25 incidents for diagnostic imaging. The majority were categorised as causing “no harm” to patients. 5 incidents were classified as causing “low harm” and appropriate actions were taken. The diagnostic imaging service had processes to investigate incidents, identify and share learning. During our review of a sample of recent incidents related to diagnostic imaging we found appropriate review and action had been undertaken in a timely manner.

There was only one radiation incident report prepared by the radiological protection centre over the preceding 12 months and appropriate action was taken.

Staff that we interviewed were confident to identify and report incidents in line with the service’s incident reporting policy, particularly regarding radiation-related incidents to the Radiation Protection Adviser. Staff we spoke with did not always receive individual feedback on incidents they had submitted. However, daily huddles as a team could be used to disseminate learning.

The evidence showed some shortfalls. The service did not always demonstrate working well with people and healthcare partners to establish and maintain safe systems, pathways and transitions of care.

The service provided some evidence of working with external partners to ensure there was a review and improvement in the continuity of care and reporting of radiological results.

Staff recorded diagnostic imaging details on the radiology department information system (RIS). A radiology information system is the core system for the electronic management of imaging. The RIS was used if an unsuspected abnormal finding was found to inform the radiologist. The radiologist would then inform the relevant department or referrer of their findings.

We were informed by patients that they were referred to the service by their GP and were satisfied with all aspects of care they received, such as how they were treated by staff, information provided, and aftercare instructions provided.

We reviewed a sample of imaging referral forms during our assessment and were mainly completed with the relevant information, legible and signed. However, some staff said that information was sometimes missing on the referral form. Some staff felt that they were not always informed of certain details before a patient arrived. For example, a patient arrived but needed a hoist. The hoist was kept elsewhere in the hospital and there was a delay in getting the hoist to the diagnostic imaging department. Staff felt that this could have been communicated better by the consultant on the referral form. Radiologists completed a report at the time of the imaging procedure or within a few days afterwards. Remote reporting was also permitted. The radiologists who undertook remote reporting had to sign to agree that they would follow the Nuffield specification for remote reporting. However, there was no system for leaders to verify that this specification was met, or the area used was appropriate, for example lighting or security. This had the implication that there was no assurance that radiologists were working in an appropriate manner.

All radiological reports were emailed the following morning after being reported and copies were kept in an electronic folder.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

During our assessment all staff interviewed, including agency staff, demonstrated awareness of who the safeguarding lead was and how to escalate any concerns.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 2 for safeguarding adults. Training compliance data for safeguarding adults showed 94% compliance for level 2. Children and young people safeguarding training compliance was completed for a small number of staff. In addition, 88% of diagnostic imaging staff had completed the Oliver McGowan mandatory training on learning disability and autism.

The Nuffield Health safeguarding adults and children and young people policy was in date and ratified in February 2025. The policy was comprehensive and clearly identified roles and responsibilities of all types and levels of staff.

Chaperones were used when required and there was a notice board in the waiting area with reference to the chaperone policy.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff attended a daily huddle to discuss the patient list for the session and review any patient issues, capacity or staffing issues and any other pressures on the service.

The service had a comprehensive and in-date identification of patient’s policy to carry out a radiological examination. This policy included reference to the Society of Radiographers “Pause and check procedure”.

The diagnostic imaging department had implemented the “pause and check” process before every patient examination started. A “pause and check” sign was observed in the clinical area. Audit results for “Pause and check” for January 2025 were good with 100% for Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) and 97% for Ionising Radiation.

Staff communicated with patients so that they understood their care and treatment. We observed staff providing an explanation of an MRI procedure and confirmed that they understood the procedure. Patients were satisfied with the care that they received.

The service had introduced Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) inclusive pregnancy status forms for all patients to complete aged 12-55 regardless of their gender. The local examination on person of childbearing potential policy had expired in March 2025 but the Nuffield Health policy including the pregnancy status procedure was in date.

A process for dealing with a medical emergency within the MRI scanner was in place. Basic life support training compliance was reported as 86% at the time of the assessment.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

An external supplier serviced and maintained diagnostic imaging equipment for the hospital. The service schedule showed that all imaging equipment received a regular service. There was evidence that new equipment was being installed.

The resuscitation trolley situated between the outpatient department and the diagnostic imaging department had daily checks undertaken. Paediatric and Adult resuscitation policies were available as well as resuscitation council guidance.

Staff said that a fault logbook was in place but was not always used. The logbook, when used, would include an incident number and an engineer would be called to rectify the problem.

Rooms were secure with access controlled using digital locks. The rooms were in general visibly clean and tidy with access to personal protective equipment (PPE). There were warning radiation lights outside doors to rooms. All X-Ray radiation rooms had appropriate signage for checking pregnancy status and identification of controlled access areas.

A sample of consumables were examined and were found to be in date although a probe used for a breast biopsy was found out date in the mammography room. We were informed that this probe was no longer used in practice.

Fire extinguishers were in date, and all MRI equipment was appropriately labelled.

The roof area above the diagnostic imaging department had a leak and was on the hospital and department risk register. Access to the roof was controlled by radiology staff and this provided assurance on maintaining safety to staff when the MRI scanner was in operation.

The diagnostic imaging department had a quality assurance (QA) lead to ensure that regular equipment safety checks were carried out. However, we were informed that the lead radiographer for QA had left in February 2025, and leaders were waiting for new staff to commence.

Evidence was provided to demonstrate that exposure to occupational radiation was being monitored as well as lead apron monitoring.

The evidence showed some shortfalls. The service was challenged to ensure there were enough permanent staff available and relied upon agency and bank staff on occasions. Staff did not have capacity to be able to carry out all their duties to provide safe care that met people’s individual needs.

Staff told us that they completed a workbook for competency assessment when they first started as a radiographer. This took about 3 months to complete, and the same process was used for agency staff.

There were high vacancy rates and a few staff where on maternity leave at the time of inspection. The radiology manager informed us that low staffing levels was one of the top risks for the department and was on the risk register. Data from April 2025 showed that the vacancy rate for radiographers was 35% and would be over 50% if bank staff were not in position. Leaders told us that it was difficult to recruit staff with mammography experience. Some new staff had commenced duties at the time of our assessment. However, staff did not always have sufficient time to undertake other duties, such as quality assurance, infection control and training. We were also informed that there was no nominated health and safety lead person at the time of our assessment. This meant that the service did not always have enough staff to ensure sufficient oversight of quality systems.

The service was currently out to recruitment and there was a reliance on the use of agency staff at the time of the inspection. Induction programmes for new and bank/agency staff were comprehensive and supportive to staff.

Agency staff that were interviewed during the inspection were aware of the incident reporting system, dose limits for radiation and other procedures. They had received safeguarding training and were very satisfied with the induction process they had received. They felt that they had been given the time to gain competency and were well supported during the induction process.

Relevant staff had access to a monthly one to one meeting with the manager and was an opportunity to discuss any wellbeing issues, development opportunities and setting departmental objectives.

Despite the concern with low staffing levels, mandatory training compliance was overall good.

Medical staff were mainly employed by NHS organisations and had practising privileges to work within diagnostic imaging. Evidence was provided to demonstrate that all medical staff were up to date with General Medical Council registration, Disclosure and Barring Service status and indemnity insurance was in place.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the assessment, we noted that the Infection Prevention and Control (IPC) lead for diagnostic imaging had recently left, and a replacement had not yet been identified to manage oversight of any IPC issues.

Examination of the clinical areas demonstrated that overall they were visibly clean and tidy such as the fluoroscopy room, mammography room, ultrasound room. However, staff did tell us that they lent into the MRI scanner to clean it using an antiseptic wipe to clean rather than using an antiseptic wipe on an extendable tube, to reduce potential exposure to a static magnetic field.

There was evidence of access to PPE, sharps bins and handwashing facilities. Staff maintained equipment although “I am clean” stickers were not always visible.

Evidence was presented that staff had received handwashing competency assessments, but no evidence was provided on audits of cleaning schedules for diagnostic imaging. This meant that we were not provided with assurance that there was oversight of cleaning undertaken within diagnostic imaging.

There were policies and procedures related to the cleaning of specialist equipment such as ultrasound probes using a specialist device.

The waiting area for patients was also visibly clean and well maintained.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were involved in planning, including when changes happen.

Medicines used in diagnostic imaging, including contrast media and injectable agents, were stored securely and checked regularly. Radiographers followed a two-person check process for administration and documentation. Batch numbers and expiry dates were recorded for contrast media, supporting traceability in the event of a product recall.

Emergency medicines and resuscitation equipment were available in imaging areas and checked daily. Staff were trained in emergency response and had access to reversal agents.

Radiology protocols were clear and followed national guidance.

Prescriptions were signed by the radiologist and documented appropriately.

Staff were knowledgeable about contraindications and screened patients for allergies and medical history before procedures.