Spire Cambridge Lea 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. Leaders had systems for identifying and responding to deteriorating patients in the department. People received treatment and care to reduce the risk of avoidable harm, which included following safety standards and safety checks prior to entering the MRI. There were safety processes arranged before procedures started, with staff working together to ensure the right patient had the correct imaging. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s 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. This meant 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.

We scored the service as 3. 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.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses in line with the local procedure. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured actions from patient safety alerts were addressed and progress was monitored.

The service had a current incident reporting and reviewing policy, which reflected the provider’s and national guidance.

We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. Incidents were analysed to identify trends or themes and potential links to individual practitioners. There had not been any repeated themes or trends in the year prior to our assessment.

There had been no reported never events in the preceding year. Never Events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harm occurring.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

Managers used changes in national guidance, incidents, safeguarding and appraisals to identify gaps in learning.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed before any diagnostic imaging and all images were based on a formal request from a member of the medical staff.

Patients requiring tests and investigations were given enough information to enable them to understand the procedure.

There were systems and processes to ensure the correct patients were treated throughout the patient journey and they only received the procedure which was intended. We walked the patient pathway and tracked patient care from admission to the department and discharge. Suitably skilled and qualified staff accompanied patients in all areas and undertook the required diagnostic procedure.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. The service used The Society of Radiographers “Pause and Check” system. Pause and check consisted of the 3-point demographic checks to correctly identify the patient, as well as checking with the patient the site to be imaged, the existence of previous imaging and for the operator to ensure the correct imaging modality was used. We observed staff always used the 3-point demographic checks in line with the correct procedure and completed these in patient notes.

All patients were required to complete MRI safety questionnaires. The safety questionnaires included asking patients if they had a cardiac pacemaker, defibrillator or other devices in their chest and female patients were asked if they were pregnant. We saw these were completed. Gowns were available for patients to change into if their clothing contained metal, such as metal zips. All referrals included patient identification, contact details, clinical history and examination requested, and details of the referring clinician/practitioner.

Patient referrals were mostly electronic, with occasional paper requests, which were transferred onto the electronic system. These were stored securely. The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity.

We scored the service as 3. 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.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training. Data showed 100% of staff had received this training. The service had current safeguarding policies, and these reflected the national guidance for adults and children.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice, from staff who had received level 4 safeguarding training, was available to support staff from Monday to Friday. Out of hours, staff reported to senior managers within the organisation, who had also received this level of training. Staff knew how to contact them. There were named staff for adult/child safeguarding. The service provided nursing and medical staff with level 3 safeguarding training for children and adults. At the time of assessment, all staff compliance was 100% for both adults and children’s safeguarding training.

Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies and staff knew what happened when they raised concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff told us they followed a process if they had concerns about a patient’s ability to make decisions about their care or treatment. This included discussing the situation with patients’ consultants, senior staff and any accompanying relatives.

The registered manager had oversight of safeguarding within the service. Patients knew what to expect and when they would be next seen by a nurse or doctor.

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. Staff had placed signs in key areas around the department, such as changing areas, advising of the availability of a chaperone.

We scored the service as 3. 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.

The service worked with patients to understand and manage risks. The treatment and care met patients' needs in a way which was safe and supportive. Staff communicated with patients so that they could understand their care and treatment. Patients told us explanations were given to them, these were detailed and patients were able to ask any additional questions they had. 

We spoke with 3 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, one patient told us staff had explained about a contrast injection (a dye injected into a vein to enhance image clarity), it’s benefits and how it may affect existing medical conditions. The patient was then able to choose whether their scan was completed with or without the contrast.

We scored the service as 3. 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.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

The design of the environment followed national guidance around the built environment. Each area had a preparation area, changing cubical, an MRI scanner / examination room and MRI control room with the post processing and reporting area. However, although the x-ray and scanning rooms were wheelchair accessible, changing rooms and toilets in the department were not large enough to accommodate a wheelchair. Patients who required support to change were required to use the x-ray or scanner rooms, although these were private and provided adequate space to move around. Patients who required toilet facilities were required to use those outside the department.

Where required areas were secure and afforded protection to patients. Access was restricted by keypad/swipe card.

We checked the equipment and found all single use items were in date. Staff members outside the MRI scanning area were able to access the scanner in an emergency if there were staff working alone in the area.

We observed staff and patients walking into the secure patient area when permitted to do so only. MRI local safety rules were in place and reflected best practise. There was signage which detailed the magnet strength and safety rule. The MRI scanners were fitted with emergency buttons which stopped scanning and switched off power to the magnet.

The service had enough suitable equipment to help them to safely care for patients. All the equipment used in the scanner met the Medicines and Healthcare products Regulatory Agency (MHRA) safety guidelines for MRI equipment.

There were handover forms used when equipment was handed to engineers and physicists for servicing and testing, as according to guidance and best practice.

There was suitable equipment provided and used correctly, such as for patients who needed assistance with their mobility or to transfer onto equipment. Staff carried out daily safety checks of specialist equipment. There was ready access to resuscitation equipment in the department. There were emergency procedure sheets for all MRI scanners.

The environment used for patient care reduced the risk of patient harm, and included for example, safe flooring, handrails and window restrictors. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

Patients could summon assistance and help as needed and we saw how patients were shown this.

The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the trust policy. Hazardous substances were stored safely and information about products was available to staff. Patients reported that lighting was reduced at night, and the noise levels were minimised

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

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

Staff included 10 whole time equivalent (WTE) senior radiographers and radiographers. The service had 5 WTE administration staff and 1 WTE healthcare assistant (HCA). The service also had bank radiography and HCA staff who were used based on the demands of the service. The service had no vacancies and during the assessment the actual staffing levels were as planned.

The service did not employ any medical staff. 30 radiologists held practising privileges and reported on private patient scans. For NHS patients medical staff employed by the host NHS trust reported on their scans.

New staff had a full induction tailored to their role before they started work. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. All radiologists were required to provide evidence of appraisal and re-validation.

Temporary bank and agency workers had a local induction to the area in which they were working. For example, staff provided orientation to the department, a check of the temporary staff member’s skills, experiences and training, and guidance and support for operating any equipment the staff member was not familiar with. One staff member explained they had a tick-list to get signed off to make sure they did not miss any explanations.

Radiologists who had practising privileges were required to provide an up-to-date appraisal. At the time of the assessment the radiologist appraisal had been completed. The service had an up-to-date practising privileges policy. Practicing privileges are granted to healthcare professional with the right qualifications, skills and experience to provide services within a specific healthcare facility, like a hospital or clinic, without being directly employed by that facility.

Managers reviewed the number and grade of clinical staff, assistants and other key roles, needed for each shift in accordance with provider and or national guidance.

Staff said they felt the service was safe. They were able to take breaks during their shift. Patients spoken with felt their needs were met in a timely way and we observed staff attended to patients in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, staff were able to access external CT scan training to update their skills and knowledge each year.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

Diagnostic imaging procedures were carried out by professionals with appropriate seniority and speciality training.

The department was open on Saturday mornings for appointments and had an on call staff member for other times over the weekend.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service managed most infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. The department was visibly clean, free from clutter and had suitable furnishings, which were clean and well-maintained. However, not all bottles of ultrasound gel were labelled with the date they were opened or the date they should be discarded. The UK Health Security Agency made a recommendation in a National Patient Safety Alert in November 2021 that all bottles of ultrasound gel be labelled with the date of opening. Staff could then ensure the bottle could be disposed of after a month, if not before, which reduces the risk to patients associated with the use of non-sterile ultrasound gel in healthcare settings.

The provider had an infection, prevention and control (IPC) policy and supporting guidance that was accessible to staff.

There was a programme of infection and prevention and control audits including for example, hand hygiene, department cleanliness and waste management.

The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas.

Staff used records and data to identify how well the service prevented infections.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

Staff followed infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the service’s PPE standard operating procedure.

Staff understood the process for managing spillage of body fluids in the department.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen. Medicines were safely stored.

Patients told us they were informed about the possible side effects, how it may make them feel and they were asked if they wanted to continue before any medicine was given to them.

For each scanner the staff had access to required medicines and there were securely stored. Emergency medicines were kept in an accessible container. Medical oxygen cylinders were stored, staff told us these were administered under patient group directions (PGDs) and standard operating procedures (SOP’s). Patient group directions are written instructions that allow registered healthcare professionals, such as nurses, to supply and administer specific medicines to pre-defined groups of patients safely, without a doctor’s prescription. The service used systems and processes to safely prescribe, administer, record and store medicines.

Staff completed medicines records accurately and kept them up to date. There was effective governance of medicines, for example, audits of storge and security of medicines, and PGD administration for November 2025 to January 2026 both showed 100% compliance.

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence if this occurred.