Spire Portsmouth Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we did not rate effective. At this assessment the rating has changed to good.

We have not awarded this service a score for Effective.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff assessed patient’s needs and these were recorded on their scanning documents. Scans and X-rays were planned and delivered in line with evidence-based, guidance, standards and best practice. There were processes to ensure the right person received the right procedure, and investigations were carried out if this did not happen to ensure people’s treatment was effective.

Patient care records we reviewed included pre-admission information, which detailed information such as allergies, communication needs, mobility needs, health conditions and details of the procedure. This helped staff to understand how to provide the right care for people. Staff took their time with patients to assess their needs when they arrived for their appointment.

Staff carried out pregnancy checks for patients before their procedures, to prevent unborn babies becoming harmed through diagnostic imaging procedures. The service provided evidence that a pregnancy check audit showed this check had occurred in 100% of cases, in-line with the services compliance target. Information for patients to inform their radiographer of any chance of pregnancy was clearly displayed throughout the department and available in multiple languages. Staff gave examples of how they would have these conversations in a sensitive and person-centred way.

The service had operational procedures for the different diagnostic imaging areas and there were local safety rules in place. These were up to date and reflected best practice.

Staff assisted patients into comfortable positions for imaging wherever possible and worked to understand what people’s specific needs were when they arrived for their appointment. Patients had access to drinking water or warm drinks as required, with a water dispenser for patient use available.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. All policies we looked at contained a creation and review date, and clear references to current national guidelines. These policies were regularly reviewed and updated. Policies and processes were updated to reflect changes in the Royal Colleges guidelines, National Institute for Health and Care and Excellence (NICE) guidelines and regulatory standards. For example, national guidance following the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) was followed by staff. The organisations IR(ME)R procedures were reviewed annually and based on advice from the Radiation Protection Advisor and Medical Physics Expert. This ensured there was expert advice into the running of the department to ensure evidence-based treatment was delivered.

There were systems to communicate changes in guidance through meetings and management newsletters. We saw notice boards displaying up to date guidance in staff workrooms and scanning areas. The scanning protocols and procedures were reviewed and approved by a consultant radiologist and Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) practitioner license holder.

There were processes to complete audits of diagnostic images, and we saw these had taken place. In April 2026, an audit completed by the service showed 44 images were rejected out of a total of 875. The image rejections were broken down into specific areas, such as the body part being imaged, to understand any themes or trends.

Quality assurance reports were carried out by the Regional Radiation Protection Service from a local NHS trust. Equipment was tested in line with IR(ME)R regulations which checked for quality and effectiveness.
Leaders told us the diagnostic imaging service identified and implemented relevant best practice guidance through a range of governance structures, including the Medical Advisory Committee and quarterly Hospital Safety, Quality and Risk committees.

Patient records we reviewed showed evidence that risk assessments were completed before scanning procedures.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Radiographers, radiologists and other professionals worked together as a team to benefit patients. They supported each other to provide good care and staff told us there was effectove teamwork within the service. This teamwork meant we observed patients receiving effective care which was in line with their needs. Staff were able to build a rapport with patients and their relatives.

Staff reported healthy working relations across staff groups. We saw and heard examples of effective team working which was based on mutual respect and trust. Staff told us they had been able to improve their professional knowledge and skills through working in partnership.

Staff explained how they shared information with healthcare professionals when further investigations or specialist review were required. Staff identified managers and clinical leads who could provide advice when concerns arose. Radiographers and radiography assistants used secure channels to communicate with radiologists and other clinicians to discuss information about patient care.

Radiology staff worked closely with the referrers to enable patients to have a prompt diagnosis and treatment pathway. If they identified concerns from scans, they escalated them to the referrer. This ensured staff could share necessary information about the patients and provide holistic care.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service had a range of information for different scans undertaken which detailed what patients should expect during the visit and how patients should prepare for their scan. This was available for people before, during and after their procedure. Patients could also access leaflets, posters and videos in the waiting areas relating to health promotion. This included physical and mental health, with information on healthy eating, breast cancer awareness and stopping smoking. Information about domestic abuse support services was displayed in patients’ toilets, providing a discreet way for patients to access guidance.

The service had a range of information available via the provider website with details on aftercare for people following procedures. For example, patients were guided on possible situations such as allergic reactions after an injection of a contrast medium.

People were given information about scans, consent processes and next steps in their care. However, some staff told us they were not involved in health promotion and that it was not part of their role. This could mean there were missed opportunities to provide holistic care and promote healthier lives for patients that access their services.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff monitored the effectiveness of care and treatment through audit and benchmarking to compare with other similar services. The service used the findings to make improvements and improve outcomes for patients.

The service participated in relevant clinical audits to monitor and improve patient outcomes. The hospital’s monthly and quarterly Quality and Safety reports included 2 areas relating to diagnostic imaging. These were radiology incidents and patient satisfaction, allowing leaders to understand any changes, themes or trends. Data from clinical audits was shared and reviewed at the hospital Safety, Quality and Risk committee meeting.

There were processes to complete audits of diagnostic images, and we saw these had taken place. In April 2026, an audit completed by the service showed 44 images were rejected out of a total of 875. The image rejections were broken down into specific areas, such as the body part being imaged, to understand any themes or trends.

Improvements had been made because of audits and information on patient outcomes. For example, new patient information leaflets had been developed, and the system for making sure patients received information before their appointment had been improved. This was to ensure patients had a safer and more positive experience of their scan.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patient consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff followed the services policies related to consent, mental capacity, and deprivation of liberty.

Patients were given information explaining their procedure prior to their scan. This meant people could consider their care and treatment and make an informed decision. Patients confirmed they had completed a safety questionnaire and were able to give consent for the procedure they had attended for.

The service had a consent policy which was up to date and provided staff with guidance on how to work in line with best practice. We observed staff seeking verbal consent before providing care or treatment, as well as checking consent throughout the process. Staff described how they gain consent from patients during breast screening procedures in a sensitive and person-centred way, acknowledging some patients may choose to withdraw consent if they feel uncomfortable or distressed. Records we reviewed showed consent had been recorded before patient underwent scans.

Consent for MRI scans was obtained and included discussion about the benefits, potential complications, the risks and alternative options. Guidance was available within staff work areas for on how to obtain consent appropriately.

Most staff kept up to date with training in the Mental Capacity Act and Deprivation of Liberty Safeguards and knew where to access the current polices. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. The service had a Do Not Attempt Cardiopulmonary Resuscitation Policy which also applied to the diagnostic imaging department.