Spire Portsmouth Hospital

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained at good.

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 their local procedure. Managers investigated incidents using the Patient Safety Incident Response Framework (PSIRF), and shared lessons learned with the whole team and the wider service. Staff apologised and gave patients honest information and suitable support if things went wrong. For example, when patients had received a higher dose of radiation because of an error with a scan, they were informed and provided with relevant information. We saw incidents like these were raised and reported correctly. ‘Flash Alerts’ were used to update staff when an incident occurred within the organisation. These were immediate notification emails sent to staff. This alert focussed on one topic and guided staff to act, such as for a patient safety alert or product recall, for example.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. For example, staff followed their duty of candour following an incident where a patient did not receive the right procedure and made a complaint. Staff received feedback from investigation of incidents and were involved in the process, with opportunities for learning to be shared within teams.

There was a current incident reporting and reviewing policy, which reflected the provider and national guidance. Staff were able to identify and report risks, and they felt confident they would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to act and prevent the risk continuing. Staff told us they had the opportunity to debrief and felt support by managers after any incidents.

We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. Incidents were reported and managed through a local electronic risk management system, with investigations conducted for patient safety incidents. There was evidence that changes had been made because of feedback. For example, changes scanning equipment to make it safer for patients to use if they had mobility needs.

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

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 prior to their scan, and all images were based on a formal request from a member of the medical team.

Patients requiring tests and investigations were given enough information to enable them to understand the procedure, so people could understand if they might not be suitable for a scan. For example, the service ensured staff were aware of patients of childbearing potential, who were or may be pregnant before they were exposed to any radiation. We saw several posters within the department alerting people to tell staff if they might be pregnant, and this was included in the risk assessment.

All patients were required to complete MRI safety questionnaires. The safety questionnaires included asking patients if they had cardiac pacemaker, defibrillators or other devices in their chest and female patients were asked if they were pregnant. We saw these were completed. Family members were asked to complete a visitor’s safety questionnaire prior to the scan. Gowns were available for patients to change if their clothing contained metal, such as metal zips.

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. The service had effective systems to receive referrals from GPs and consultants. All referrals included patient identification, contact details, clinical history, examination requested and details of the referring clinician or practitioner. There was admission criteria for both private and NHS patients. Suitably skilled and qualified staff accompanied patients in all areas and undertook the required diagnostic procedure. If patients did not attend their appointment, staff followed this up.

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” involved completing the three-point demographic checks to correctly identify the patient, confirming the imaging site with the patient, verifying any previous imaging, and ensuring the correct imaging modality was selected. We observed staff used the 3-point demographic checks in line with the correct procedure.

Patient records were a mixture of electronic and paper based and were kept securely. We saw current and up to date paper based forms available for staff to use. The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

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 which was mandatory. There were current safeguarding policies, and these reflected the national guidance for adults and children, including where children were visitors. Policies were subject to regular review with a documented review date and staff were aware of these policies.

Leaders shared learning from safeguarding concerns and incidents with staff. For example, a learning event hosted by the safeguarding lead was held for teams on the topic of Coercive and Controlling behaviour during National Safeguarding week in November 2025.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had posters around the hospital informing staff and patients who to contact to raise concerns. Safeguarding advice was available to support staff within the service. The director and deputy director of clinical services were the safeguarding leads for the hospital. They were level 3 trained which meant they were able to investigate safeguarding issues when required.

Safeguarding concerns were considered when an incident occurred and a referral or further advice would be 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. For example, staff were aware of how someone who was known to be vulnerable not turning up to an appointment could be a safeguarding concern.

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

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. Patients we spoke to during our assessment told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, people had received information before their appointment and felt able to ask any questions or raise concerns.

Staff completed risk assessments for each patient on arrival. Patients completed safety screening questionnaires to ensure they were suitable to be scanned and enter the diagnostic imaging environment. We observed patients completing this form with staff. Staff involved carers of patients by asking them about the patient and how best to care for them.

Staff were confident in escalating unusual findings and told us there was an effective system to manage this. Communication with patients during scans meant staff were able to identify and respond if a patient’s condition deteriorated.

The service ensured radiation doses were kept as low as reasonably practicable. Dose reference levels were clearly displayed and the manager undertook an annual audit of doses, to ensure they were within legal limits. Radiation risk assessments had been carried out to manage the risk to patients within the scanning environment.

Patients could call for assistance and help as needed and we saw how patients were shown this. For example, patients could use an emergency call bell when in the MRI scanner if they needed assistance or became distressed. The design of the imaging rooms meant staff were able to clearly see patients whilst having their procedure, helping them to have oversight and identify risks. The service had suitable facilities to meet the needs of patients’ families and carers when necessary.

The MRI scanners were fitted with emergency buttons which stopped scanning and switched off power to the magnet. Staff talked us through what they would do in an emergency and understood risks well. For example, there was good understanding across staff, including receptionists, of risks associated with MRI scans and the checks which need to be done.

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. Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the trust policy. Patients told us they felt the environment of the department was clean and safe.

Risk assessments addressed environmental occupational safety as well as considering environmental risks to patients and their escorts. The service was also supported by an NHS trust medical physics service to ensure radiation equipment was safe and doses were well controlled.

We observed staff and patients walking into the secure patient area only when permitted to do so. Controlled areas were clearly marked and visible, preventing patients or staff from accessing them inappropriately. Local safety rules were established and embedded and reflected best practise, which we found were understood by staff. We observed the safety checks of the equipment being carried out with patients and these were in line with best practice guidelines.

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.

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 a schedule for the servicing of diagnostic imaging equipment to ensure it operated properly.

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, and staff told us how they could easily report equipment failure or problems through their system.

The environment used for patient care reduced the risk of patient harm. Flooring was in good condition and areas were free from clutter. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction. A policy was available for managing spillages of hazardous substances, and spillage kits were accessible for staff. There was easy access to resuscitation and anaphylaxis equipment in the department, which staff knew how to access. Where required areas were secure and protected patients. Access was restricted by keypads to prevent unauthorised access to high risk areas.

However, in the diagnostic imaging department, we found sharp items stored in an unlocked cupboard. As this was in a corridor near to the patient areas, there was a risk of harm occurring from unsafe storage. When we raised this with the service, they took steps to ensure the items were stored securely to reduce the risk.

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 usually had enough clinical staff 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. Diagnostic imaging procedures were carried out by professionals who had received speciality training.

The imaging manager used a staffing calculator tool to understand how many staff were needed to run the service safely and effectively. The model used by the service was to staff 85% of shifts with permanent staff and 15% with temporary bank staff to provide flexibility. Leaders received a monthly report of staffing performance. Data submitted by the service showed staffing levels had mostly met the requirement indicated by the service.

The lead CT radiographer had recently left the service, which meant there was 1 full time CT radiographer and a bank CT radiographer available. The majority of staff told us they felt they were able to deliver safe care and treatment, and we observed patients not having to wait to be seen. However, we heard from a small number of staff this has increased the pressure in carrying out all the duties of their role due to the lack of the extra staff member.

Staff told us they felt proud of how they were able to spend enough time with patients during their appointments, helping them to build rapport and meet their needs more effectively. Many staff members told us they enjoyed working for the service and felt proud of the work they do.

New staff had a full induction tailored to their role before they started work. Newer staff told us they felt supported during their induction and felt able to access the support and guidance they needed. Bank workers had a local induction to the area in which they were working. Staff working for the service received appraisals and clinical supervisions.

Radiologists who had practising privileges were required to provide an up to date appraisal. 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.

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, the Delivering Clinical Excellence programme had supported some staff in their professional development and spoke positively about this. Learning was also shared with staff during Friday Feedback meetings.

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.

We saw evidence showing if poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

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 infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. Most pieces of equipment and the premises were visibly clean. There was a provider infection and prevention and control (IPC) policy and supporting guidance that was accessible to staff.

Staff and leaders took part in infection and prevention control audits. For example, staff showed 100% compliance in a recent hand hygiene audit. There were enough handwashing and sanitising facilities for staff and patients to use.

However, the cleaning schedule had not been fully completed in one x-ray room, which we raised with the manager during the assessment. During May 2026, there were 6 days where no entry had been completed to show the required areas had been cleaned and inspected properly. On these days, there was also no entry indicating the room had not been used, therefore cleaning would have been required. Although this was a documented risk on the risk register, it was unclear how the service planned to mitigate this risk. We also found a diagnostic scanner a piece of equipment that was not visibly clean. When raised with staff this was addressed promptly.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. 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. They involved people in planning, including when changes happen.

Staff had access to required medicines, and these were securely stored for each scanner. The service had patient group directions (PGD) for radiographers to supply medicines. PGDs provide a legal framework that allows some registered healthcare professionals to administer medicines within their scope of practice, so the patient does not have to be seen by a prescriber.

Policies were available for the use of contrast agents, used in diagnostic imaging to improve the visibility of structures in the body. The policy followed national guidance and staff were guided on how to identify and response to any risk associated with using injected contrast agents. These were stored safely and securely, and temperature monitoring was carried out.

Staff carried out safety checks before all scans, including those using contrast agents. Staff completed documentation to ensure they recorded the patients’ medical history, which allowed to staff to understand whether there were any risks associated with medicines. Staff completed medicines records accurately and kept them up to date.