Nuffield Health North Staffordshire Hospital

On this page

• 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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. There were systems for identifying and responding to deteriorating patients in the department. Staff involved patients to reduce the risk of avoidable harm before procedures. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patients gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

At our last assessment we rated this key question good. At this assessment the rating has remained good. Patients were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses through the electronic reporting system in line with local policy and could give examples of incidents they had or would report. We saw evidence that incident feedback was shared at radiology department meetings, as well as shared learning from other Nuffield sites. The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance.

We viewed a sample of recent incident reports and saw evidence that managers investigated incidents and took action to reduce the risk of recurrence. When things went wrong, managers gave patients honest information and suitable support, and we saw examples where patients and their loved ones had participated in after action review meetings.

There had been 1 incident reported to Care Quality Commission as a significant accidental and unintended exposure under Ionising Radiation (Medical Exposure) Regulations 2017 in the 12 months before the inspection. The incident involved higher than intended doses of radiation being delivered to patients after an x-ray machine had undergone routine maintenance. Managers identified missed opportunities to prevent the incident including quality assurance not being performed by staff after the maintenance, and staff not recognising that some doses were above service dose reference levels. Since the incident, all staff have been trained to carry out equipment quality assurance and procedures have changed so that equipment will not be accepted back into the care of the service until quality assurance has passed. Furthermore, regular dose reference audits were carried out.

There were no never events in the 12 months before the inspection.

The provider analysed incidents to identify trends or themes, but no specific themes were identified in relation to diagnostic imaging. Cross-site learning took place during 'Lunch and Learn' Fridays, a recorded meeting where staff and leaders discussed incidents, trials and projects.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed prior to referral for imaging, and referrers were required to provide information to aid safe examinations such as pregnancy status, and information on implanted medical devices. Clinical staff vetted referrals to ensure they were appropriate before booking. The service had clear guidelines as to which examinations could be vetted by radiographers and which required radiologist vetting. Staff had access to a list of approved non-medical referrers and which examinations they could request to ensure referrals were within their scope of practice.

There were systems and processes to ensure the correct patients were treated throughout the patient journey and they only received the intended procedure. We observed staff carry out 3-point patient identification checks, check the site and side to be imaged as well as any previous imaging in line with the Society of Radiographers’ ‘Pause and Check’ system.

Radiographers were confident to escalate urgent and unexpected findings on imaging to radiologists for reporting. There were systems in place for radiologists to communicate critical findings to referrers.

Staff scanned any paper-based patient records onto patients’ electronic records to ensure they were kept securely and available across the service.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children and young people’s safeguarding training. Clinical staff received training to level 2 and clerical staff to level 1. Data showed that all but 1 member of staff who had not completed the children and young people’s module were compliant with training at the time of inspection. There were current safeguarding policies, and these reflected the national guidance for adults and children, including where children were visitors.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff could give examples of concerns they had or would report. Staff knew who to inform if they had concerns. Safeguarding advice was available from the named hospital safeguarding lead, the director of clinical services, who had received training to level 3. Staff and leaders could access further support from level 4 trained staff, and the level 5 trained national safeguarding lead. We saw evidence that safeguarding concerns were also recorded on the electronic reporting system.

Staff followed safe procedures for visitors attending the department. The service had an up to date chaperone policy, which all patients were informed of when they attended the service.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patient to do the things that mattered to them.

The service worked with patients to understand and manage risks. All patients for magnetic resonance imaging (MRI) were emailed out MRI safety questionnaires along with their appointment letters. They were also encouraged to call in if they had any implanted medical devices that may mean they were unsuitable for MRI. Staff could access advice from a medical physics expert about implant safety through an email form, and said the service used was very responsive. We observed radiology department assistants and then radiographers run through the questionnaire with patients before their scan to ensure they were safe to proceed. Staff carried out further checks on patients who were to receive contrast media as part of their examination, and had access to point of care kidney function testing to ensure patients with known kidney problems or a greater risk of low kidney function were safe to receive contrast. We observed staff waiting 15 minutes after administration of contrast before removing intravenous cannulas in case of any late development of allergy symptoms. Staff had ready access to an anaphylaxis kit which was in date.

Patients aged between 12 and 55 years undergoing tests involving ionising radiation completed a form to exclude pregnancy. We viewed a notice in the imaging waiting area encouraging transgender or non-binary patients who were assigned female at birth to confidentially disclose this to staff so that pregnancy could be safely excluded. Pregnancy test results for patients undergoing x-rays in theatre were available to staff on the electronic patient record system.

The patients we spoke with during our inspection said that they had been given information about their appointment before they arrived, and that staff had explained their tests to them in a way they could understand. Staff had systems to ensure they could communicate with patients during their procedure. A patient who was claustrophobic had disclosed this to the staff in MRI and said they checked in on them throughout the scan as requested.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not always make sure equipment, facilities and technology supported the delivery of safe care or that there was appropriate mitigation of the risk.

At the time of the inspection, the computed tomography (CT) and MRI scanners were just over 10 years old, having been transferred to the service in January 2026 from another provider who previously held the contract for these services. Mammography equipment was also 10 years old. As per the Royal College of Radiologists, equipment older than 10 years is often technologically obsolete, may produce lower quality images, may be slower, and may deliver greater radiation doses than necessary. However, there were plans in place to replace the aged equipment in 2027.

However, the design, maintenance and use of facilities, premises and equipment generally kept people safe. The environment was uncluttered and appeared well-maintained. Staff carried out an environmental audit in March 2026, and the department scored 47 out of a possible 50 points.

Warning lights were visible in areas where examinations involving ionising radiation took place. Staff were aware of controlled areas in both magnetic resonance imaging (MRI) and modalities involving ionising radiation, and access to them was restricted.

Staff had ready access to lead personal protective equipment, and we saw evidence that visual and computed tomography checks for integrity had been carried out in April 2026 and September 2025. Staff working in modalities involving ionising radiation wore personal dosimeters to monitor their radiation exposure which were analysed quarterly by a third-party provider. The report was accessed centrally by the Nuffield Health Radiation Protection Team, and processes were in place if exposure levels were too high. However, staff told us that it sometimes took a long time for reports to be sent to the radiation protection supervisors in the department.

Staff carried out imaging equipment specific competency training which 100% of staff were compliant with at the time of inspection. Staff in all modalities consistently carried out quality assurance checks on equipment in between formal servicing and said they were confident to report faulty equipment. All formal servicing of imaging equipment was up to date, including calibration of the gamma probe used in theatre for sentinel lymph node biopsies.

A member of staff was the named medical devices lead for the service and attended quarterly medical devices forums where information such as patient safety alerts and any medical devices incidents were discussed. Medical devices such as patient monitors were serviced by a third-party provider and were all in date. Ancillary equipment such as chairs, wheelchairs, and a patient trolley were labelled as MRI safe, conditional and unsafe in line with Medicines and Healthcare products Regulatory Agency safety guidelines. However, some pieces of equipment such as the contrast pump and wheelchair did not state what the conditions were. A non-magnetic fire extinguisher was available close to the MRI room and was within its routine service dates.

Emergency buttons and pull cords which summoned help from the emergency response team were accessible throughout the department. Staff from the outpatients department were responsible for checking emergency equipment. Please see the outpatients report for full details.

Waste was segregated in accordance with provider policy, and hazardous substances were stored safely in locked cupboards. Staff had access to an eye wash kit that was in date.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service generally had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

Managers used a staffing tool to calculate clinical and administrative staff hours required based on activity. Actual staffing met or exceeded ideal staffing between March and May 2026, although staffing levels were under ideal levels in June 2026, at between 79-87% of ideal levels. The service did not use agency staff. The service employed bank staff, although bank staffing accounted for just 1% of staffing hours. In the 12 months before the inspection 2 staff members had voluntarily retired or resigned, although both had returned to the service as bank staff. Sickness absence was low in the service, at less than 3% in the 12 months before the inspection.

We viewed the staff files of 3 staff and saw they all had an up to date enhanced disclosure and barring check on file, although 1 of the staff members did not appear to have an adult workforce check on file, only a child workforce check. This was fed back to senior leaders and rectified after the inspection. Where applicable, there was evidence of valid professional registration. New staff had a full induction tailored to their role before they started work. The service also provided student radiographers on placement with an induction. Managers supported staff to develop through constructive recorded, annual appraisals more frequent 1 to 1 check ins. Staff spoke highly of the appraisal process, although managers said that some staff struggled to navigate the online system and required additional support.

Staff completed a programme of mandatory training appropriate to the service and its needs. Modules included basic life support, infection prevention and control, patient handling and health record keeping. At the time of the inspection, almost all staff were compliant with all training modules. One radiographer had not completed basic life support training, and 2 radiographers had expired practical aseptic non-touch technique training. Staff said they could complete online mandatory training in work time, and we observed a member of staff doing so during a quieter period. Staff who undertook intravenous cannulations completed a yearly competency check. The service did not directly employ any medical staff, all radiologists held practising privileges. Radiologists were required to sign an annual self-declaration that mandatory training including basic life support training was up to date; the service did not directly monitor completion of their mandatory training.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, a radiographer was about to undertake postgraduate training in mammography. The service also delivered annual training on radiation protection and safety to non-radiology staff. Radiographer reporting was not supported by the service at the time of inspection.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading. There were gaps in practice which increased the risk to patients.

The department was generally visibly clean and had suitable furnishings which appeared clean and well-maintained. However, we observed dust on the mobile x-ray machine which was used throughout the hospital. This was fed back to the radiology manager, and the issue had already been rectified. The service had cleaning checklists for clinical staff in each modality to complete. While some checklists were consistently filled, others were not. For example, we viewed the CT/MRI cleaning checklist for the week commencing 29 June 2026. Daily cleaning of both scan rooms including the scanners and patient tables had not been completed on 2 out of 5 days in CT, and 3 out of 5 days in MRI. The cleaning of office equipment such as telephones and computers had not been recorded at all. Therefore, staff and managers could not be assured that cleaning had taken place. There were no cleaning checklists for ‘c-arms’, equipment used to take x-rays in operating theatres. Staff told us that after cleaning the c-arms, they would apply a ‘I am clean’ sticker with the date of cleaning on. However, on viewing the equipment in the theatre storeroom, no sticker had been applied, therefore staff could not be assured when the equipment was last cleaned. There was a sticker on the lead personal protective equipment in the same storeroom. Staff generally cleaned equipment in between patients, however on 1 occasion we observed CT staff not wiping the patient table between patients, instead replacing the disposable paper on top.

There was a provider infection and prevention and control (IPC) policy and supporting guidance that was accessible to staff. All staff were observed to be arms bare below the elbow to allow for full hand decontamination and adhered to the provider’s uniform policy. Staff had access to hand sanitiser and handwashing facilities which they used in between patient contacts. The service carried out a 4 monthly hand hygiene audit, whereby the practice of 10 staff members was observed. Staff generally performed well on the audit; however, we saw evidence that where a staff member had not adhered to best practice, a manager carried out a reflective review with them. Staff had access to personal protective equipment, and we observed them using it appropriately, such as when removing an intravenous cannula. When undertaking a sterile procedure in ultrasound, staff maintained aseptic technique. We observed decontamination of ultrasound probes using specialist equipment. The equipment printed stickers when decontamination was completed to be added to patient records.

Sharps boxes were correctly assembled, labelled and not overfilled. Cleaning checklists for non-clinical areas such as waiting areas, toilets and changing rooms completed by domestic staff were consistently completed. No water outlets in the department had been identified as little-used outlets for inclusion in the hospital’s formal legionella management programme, however, tap running had been added to the cleaning checklist for domestic staff.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

The service had an up to date standard operating procedure, ‘Management of Medicines in Radiology Departments’ to support the staff procurement, storage, administration, documentation and disposal of medicines.

Staff ordered contrast media and other medicines from the internal pharmacy and safely stored them in locked cabinets; keys were securely stored in staff areas. We viewed a sample of medicines and consumable items for the administration of medicines and found them to be in date. Staff told us that a named radiology department assistant was responsible for a weekly stock check to ensure items did not expire. The service had embedded patient group directions (PGDs) for contrast media and select other drugs. PGDs allow qualified health professionals, in this case radiographers, to administer specific medicines to a pre-defined group of patients without needing an individual prescription or direct instruction from a doctor. However, staff told us that the current PGDs excluded a significant number of patients, including those with diabetes or cardiovascular disease. This meant that individual prescriptions had to be sought from radiologists. This was being addressed in a project by staff in the CT steering group at the time of inspection. Staff recorded the batch number and expiry date of medicines administered on paper forms which were scanned into the electronic patient record.

The service generally performed well in medicines audits. In the most recent medicines management audit of July 2025, the service scored 91% and 86% in the medicines security audit of August 2025. We saw evidence that actions highlighted in both audits had since been completed.