Spire Norwich 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 was safety processes arranged before procedures started, with staff working together to ensure the right patient had the correct imaging. 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 people 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 not always learnt to continually identify and embed good practice.

Staff we spoke with demonstrated an understanding of the service’s incident reporting policy, and felt confident in identifying and reporting incidents, including those relating to radiation exposure, in line with established processes and escalation to the Radiation Protection supervisor (RPS).

Between March 2025 and February 2026, 15 incidents were reported. Most incidents were categorised as no harm, with 1 classified as low harm. Appropriate actions were taken in response to the incidents reported. There were no serious incidents in the last 12 months.

The diagnostic imaging service had processes to investigate incidents and identify learning; however, evidence that learning had been consistently embedded into practice was limited. Evidence showed that ‘wrong site examination’ and ‘unjustified radiation exposure’ were recurring. Learning was shown from these incidents, however, no detail was provided on how these incidents occurred.

Staff understood duty of candour. This meant that the service was open and transparent with people about using their services, whether something has gone wrong.

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.

There was an Identification process in place to ensure the correct patients were treated and only received the procedure which was intended. This followed the Ionising Radiation Medical Exposure Regulations 2017 (IRMER).

As part of our inspection, we reviewed a sample of 5 imaging referral forms, which staff had completed with relevant information. The forms were legible and signed. Staff confirmed that they considered patients’ needs through a pre-assessment conversation prior to their appointment. This included information about any required reasonable adjustments. They also informed patients of the next steps and provided contact details to ensure continuity of care after the imaging procedure.

Consultants submitted referrals on paper; however, staff accessed diagnostic imaging details and radiological reports through an encrypted electronic system. The service had a pool of reporting radiologists. There was a protocol in place to escalate urgent findings to the referrer. Radiographers and radiologists flagged urgent findings by contacting the relevant referring consultant by email or phone.

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.

During our assessment, all staff we spoke with demonstrated a clear understanding of who the safeguarding lead was and how to escalate safeguarding concerns appropriately. Staff described a safeguarding concern they had managed, including the actions taken, the outcome, and how they worked with other agencies to ensure the individual’s safety.

The service provided safeguarding training that was specific to staff roles. All staff had completed safeguarding training to level 2 for both adults and children, which supported their ability to recognise and report safeguarding incidents. There was a safeguarding lead in place and staff were able to provide recent examples of how they protected individuals from harm.

Staff used chaperones when required. The magnetic resonance imaging (MRI) team on the day of the inspection consisted of 2 male radiographers. Staff informed us that they made patients aware in advance that the radiographers were male and that patients could request a female chaperone if required. Staff told us they had not had any complaints in relation to this.

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.

Staff communicated effectively with patients to ensure they understood their care and treatment. We observed staff explaining a Magnetic Resonance Imaging (MRI) procedure and checking patients’ understanding. Patients we observed told us they were satisfied with the care they received.

Senior staff from each department attended a daily hospital huddle to review any issues, complaints, capacity, staffing and any other pressures affecting the service. Senior staff shared a summary of the huddle with all senior team members by email. Staff told us that senior management also informed them verbally of any issues. Staff explained they could escalate concerns to their manager, who could raise these at the daily huddle.

The service had a comprehensive and up-to-date identification of patients policy in place for carrying out a radiological examination. The policy aligned with guidance from the Royal College of Radiologists.

The service had a clear process in place for managing medical emergencies within the MRI scanner. Staff demonstrated awareness of this process and how to respond in the event of an emergency.

The service used a translation service for patients who did not speak English. The service did collect feedback from patients via a survey.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment followed national guidance, most areas of diagnostic imaging were visibly clean, well maintained and free from clutter. However, the CT scanner and a secondary ultrasound room were located in the MRI area. This meant that the safety zone of the MRI scanner was compromised. The provider stated that they only used this room if the other ultrasound rooms were at full capacity and the last time it had been used was 3 months ago. The provider said they would immediately cease use of this room and have plans to create a new one. However, no date for completion was confirmed during inspection.

At the time of inspection, the Radiation Protection Supervisor (RPS) name and number was not clearly visible on control area doors in line with guidelines. Following the onsite visit this was rectified by the service and evidence provided.

Several external companies serviced and maintained the hospitals diagnostic imaging equipment. Service records confirmed that all imaging equipment had received regular servicing.

Staff completed daily and weekly checks of the resuscitation trolley. The trolley was located in the MRI area and all weekly and daily checks had been completed appropriately. All equipment was found to be present and in date.

The service had digital locks with swipe access installed at the entrance to the diagnostic imaging department and throughout the department.

The provider supplied evidence to demonstrate that they routinely monitored staff exposure to occupational radiation, including the monitoring of lead aprons.

We reviewed a sample of consumables and fire extinguishers and found that all items were within their expiry dates.
Staff highlighted that there was a piece of imaging equipment known as the C-Arm which was very heavy and hard to operate. This posed a manual handling risk, although a manual handling risk assessment was in place. The provider stated that the device had been checked by an engineer and is not faulty. Provider stated this was to be replaced soon as procurement has been approved.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff.

They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

During our inspection, staffing levels were proportionate to the service requirements. We were informed that MRI had vacant positions and were currently utilising bank and agency staff.

Staff induction periods varied. Staff felt that they were given sufficient time to become familiar with protocols. For example, an agency member of staff informed us they were given a 1-week induction. We were informed this was a normal expectation for agency staff across the providers that the radiographer had been to and felt it was adequate. All induction and training paperwork reviewed was up to date and relevant to staff roles.

Staff told us that manager, including the RPS were approachable and supportive.

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.

All areas that we inspected were visibly clean, well maintained and free from clutter.

The service managed infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

There was a provider infection and 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 we saw evidence that hand hygiene and local cleaning audits were done regularly and showed good compliance.

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.

We saw staff were following 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.

Medicines were stored securely, with appropriate temperature monitoring, and access was restricted to authorised staff.

Patient Group Directions (PGDs) are written instructions that allow specified registered healthcare professionals to supply and/or administer a medicine directly to a predefined group of patients who meet the criteria set out in the direction, without the need for an individual prescription.

The service had UpToDate PGDs and most staff were trained and authorised to use these documents. We saw two members of staff had not been authorised by the provider to administer these medicines.