The Newcastle Clinic

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 assessed all 8 quality statements from this key question for the service. This means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated inadequate. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment. The service did not have effective systems to assess the risks to people's health and safety during any care or treatment or to ensure that medicines were managed safely. The service did not have arrangements to take appropriate action if there was a clinical or medical emergency.

The service was in breach of legal regulations in relation to safeguarding service users from abuse and improper treatment. The service did not have effective processes in place to prevent the abuse of service users and staff had not received safeguarding training suitable for their role.

The service was in breach of legal regulations in relation to good governance in that they did not have robust have systems and processes that assured compliance with statutory requirements, national guidance and safety alerts.

The service was in breach of legal regulations in relation to staffing in that it did not ensure that staff had the qualifications, competence, skills and experience to keep people safe.

The service was in breach of legal regulations in relation to fit and proper persons employed in that they did not have systems in place to evidence checks in line with Schedule 3 of the Health and Social Care Act 2008 including DBS, photographic identification, curriculum vitae (CV), qualification certifications, health declarations and references.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service had an incident reporting policy, but not all staff could access it online. The service held an incident report log, but leaders told us that this was not kept up to date and they were unsure what incidents had been reported and investigated. Following our on-site assessment, we requested the current version of the incident log, but the service failed to provide one.

Leaders told us team meetings did not take place with the radiographers which meant lessons learned following incidents or complaints were not shared with the team. Therefore, there was no clear process for ensuring lessons were learned. There were missed opportunities to learn and improve. Staff told us they did not always have time to report incidents.

Staff we spoke with understood the duty of candour and provided an example of what this meant in practice and gave a good example of a change to scanning criteria as a result. Staff told us that duty of candour training was delivered as part of the service’s mandatory complaints handling training, though records illustrated that over 50% of staff had not completed the training.

People who used the service told us they felt safe and did not have any concerns around safety incidents. They understood how to raise any concerns with staff.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

The service did not have a robust policy for dealing with medical emergencies. This placed staff and people using the service at additional risk. Staff told us they carried out routine observations of people with deteriorating health who would then be stabilised and transferred to the local NHS hospital if they required emergency treatment.

All life support training for clinical and support staff was out of date. Staff told us this was due to issues with training funding. There had been no instances in the past 12 months where a person required emergency transfer to hospital.

The service had structured care pathways in place to ensure continuity of care but did not have a documented inclusion or exclusion criteria. There were effective processes in place to refer patients to other services if needed. The service collaborated with general practitioners (GPs), and in house consultants, maintaining clear communication and documentation. As treatment was provided on an outpatient basis, continuation of people’s care was maintained by the clinician who had referred the person to the service.

Following the scan, the service provided the referring clinician with a detailed report. The patient was also provided with a copy of their images and report for their own records. Treatment decisions were made by the referring clinician. In urgent cases, staff working in the service would contact the referring clinician directly to ensure they were aware of the results and could take action as needed.

Staff liaised with people’s GP if there were any queries around a person’s health status or if any test results were required, prior to attending for scans.

We collected feedback from external partner services that worked collaboratively with the service. Partner feedback was very positive about safety and continuity of care.

Patients reported a collaborative approach and good communication between the service and their referring consultant or GP.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The service did not have a robust safeguarding vulnerable adults’ policy. It did not include details of safe recruitment of staff, training requirements and designated safeguarding leads. Despite being registered to treat children the service did not have a safeguarding children policy.

Not all staff had training on how to recognise and report abuse and leaders where not monitoring training requirements effectively, however those we spoke with understood how to protect people from abuse. The nominated safeguarding lead was not trained to safeguarding level 4 and they were unsure what the requirement of the role entailed.

The service did not always ensure new starters completed Disclosure and Barring Service (DBS) checks before they started in role.

There were no clinical governance meetings being held at the service where safeguarding concerns could be raised.

However, people who used the service told us they had not experienced any instances of abuse or neglect at the service. They told us if they had any safeguarding concerns, they would raise them with the managers.

The service did not always work well with people to understand and manage risks.

We saw from patient records that all patients underwent a risk assessment and gave written consent to the diagnostic test before their scan. The department used an MRI patient safety questionnaire; however, we found that these were not always attached to the patient record.

The service had one permanent radiographer and utilised bank radiographer staff. They had access to a Radiation Protection Supervisor but not all staff we spoke with were aware of how to contact them with concerns in relation to compliance with the regulations or incidents involving radiation exposure.

Safety huddles and briefs where key risks could be reviewed and discussed were not being held.

Not all staff we spoke with knew about the mental capacity act or the deprivation of liberty safeguards. Although the service generally saw healthy patients, staff could not give examples of what they would do if a patient required this support.

Patients told us they were involved with the decision making about their treatment. Patients knew who to contact if things went wrong and felt informed about the treatment they were going to have or had received.

The service did not always detect and control potential risks in the care environment.

We did not see any evidence of environmental or Control of Substances Hazardous to Health (COSHH) risk assessments being completed.

Emergency resuscitation equipment and medicines were kept securely however log sheets were not always completed and we found some single use items that had gone beyond their expiry dates.

The clinical staff demonstrated an understanding of the requirement for Local Rules in both MRI and X-ray, in line with the MHRA Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use and the Ionising Radiation Regulations 2017, Part 4, Regulation 18. However, the service was unable to provide a copy of the MRI Local Rules, and the MRI Risk Assessment was overdue for review since February 2022. Additionally, the service had not formally appointed an MR Responsible Person or an MR Safety Expert, although staff showed awareness of these roles and their responsibilities.

The X-ray Local Rules were due for review in December 2024. While a Radiation Protection Supervisor (RPS) had been appointed, this appointment had not been confirmed in writing. Furthermore, the Radiation Risk Assessment had not been updated and continued to reference equipment that had since been replaced.

The local Fire policy statement did not detail the MR environment or its associated risks.

The design of the environment followed national guidance around the built environment. Where required areas were secure and afforded protection to patients. Access was restricted by electronic key cards. Staff told us there were sufficient quantities of equipment and consumable items and they could easily access them when needed.

All the areas we inspected were well-maintained, free from clutter and suitable for providing safe care and treatment.

The service used a third-party company that actively managed building maintenance including fire safety, legionella testing and oxygen storage.

Service contracts where in place for the MRI, ultrasound and Image Intensifier.

Feedback from patients we spoke with was positive regarding the environment and they did not raise any concerns regarding the clinic’s facilities.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

We reviewed 8 staff recruitment files during our assessment. We found that the service did not follow its own recruitment policy and there were significant gaps in every staff recruitment file we viewed including but not limited to missing DBS certificates, qualifications, employment histories, health declarations and identifications.

The service employed consultants on a part time basis by granting them practicing privileges, however the service did not follow its own recruitment policy and had no medical advisory committee (MAC) in place to authorise the formal granting of practicing privileges and there was no documented evidence of these in staff files.

We were told that the provider had withdrawn funding for training for face-to-face training and that access to the mandatory online training had been removed. Leaders were not monitoring training compliance and provided us with a training matrix which included staff who had left the service over 12 months previous and excluded staff new to the service.

We were provided with an updated version of the services training matrix following our assessment which showed that overall mandatory training compliance was less than 50% but the provider could not guarantee this was an accurate reflection of training completed.

Staff and leaders told us that no appraisals had taken place for over 12 months and there were none currently planned.

The service had no registered manager in post since April 2024 but we were shown evidence on site that a new application was in progress, but there had been some administrative issues with regards to the application.

We were told by leaders that bank staff did not have their training records reviewed prior to commencing employment as their primary employer was responsible for training. We did not see any evidence of bank staff induction being recorded.

The service was actively recruiting for a radiographer post. This did not impact on safe staffing as the service planned their clinic lists based on current staffing. The service utilised bank radiographers to cover annual leave and to arrange additional clinic lists. The service had remote reporting of scans by radiologists all over the country.

The service did not always assess or manage the risk of infection. The service did not have an infection prevention and control policy.

The service did not undertake regular IPC audits to monitor compliance with hand hygiene and general IPC principles including the environment and equipment.

Clinical waste was stored in a locked clinical waste bin behind the premises but was not held within a secured compound meaning members of the public could access it. The service had a clinical waste collection service level agreement, however leaders were unable to provide copies of clinical waste consignment notes.

We were provided with an updated version of the services training matrix following our assessment which showed that training compliance for IPC level 1 and 2 training to be at 66% but the provider could not guarantee this was an accurate reflection of training completed.

Leaders could not evidence vaccination records for hepatitis B for all clinical staff as required by NHS guidelines for health care workers as they did not collect this information from staff in line with Schedule 3 of the Health and Social Care Act 2008.

The service had a contract with an external company to provide cleaning services, and we observed the service being cleaned during our assessments. We asked for but were not provided with cleaning schedules and cleaning checklists.

We undertook environmental audits of the service and found that the clinical area and equipment where clean; however, we found out of date hand sanitising gel in the ultrasound clinic.

Hand washing facilities were available in clinical areas and patient waiting areas.

Patients told us they thought the environment was clean and they were happy with the facilities. They told us staff used gloves and aprons when providing care and treatment. They told us staff washed their hands before making contact.

The service did not make sure that medicines and treatments were safe and met people’s needs.

We asked for but we were not provided with the services medicines management policy.

We asked for but did not receive any of the services prescribing audit data with the provider informing us this was not undertaken.

The service did not monitor the storage temperature of any of their medicines.

We reviewed patient medical records, and it was not clear how contrast medium for MRI scans was being prescribed. Staff told us that if a referring clinician selected contrast required on the referral form the service assumed the clinician had prescribed the contrast. Staff and leaders were unable to tell us if referring clinicians where aware of this process.

Patient group directions (PGDs) which allow clinical staff to supply medicines to specific patient groups were not in place.

We found gaps in patient records with regards to the recording of contrast medium administered in that staff did not record the name or dose of the contrast prescribed.

The service did not always keep records of proper disposal of medicines.

People we spoke with did not raise concerns with us regarding medicines and pain management.