Spire South Bank 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

The service did not always detect and control potential risks in the care environment. There was not always enough or suitably trained staff to ensure patients were safe and the service met demand. The service did not always manage infection risks well. The service did not always make sure that medicines and treatments were safe

However, we found:

The service had a proactive and positive culture of safety. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers. Patient risks were managed collaboratively with the patient. Staff provided care to meet patient’s needs which was safe and supportive.

This was the first assessment for diagnostic screening. It was previously inspected in 2016 jointly with outpatients and we rated this key question as requires improvement. At this assessment the rating remained requires improvement. This means patients were not always 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.

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.

Staff recognised and told us they reported incidents and near misses in line with the service incident reporting procedure. Staff knew what incidents to report and how to report them. An electronic system was used to report incidents and staff we spoke to had access to it. From April 2025 to March 2026, 13 incidents had been reported, categorised as either no harm or low harm incidents. 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.

There had been no incidents requiring reporting under Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). Providers must report incidents where a patient receives a much greater dose of radiation than expected.

Managers investigated patient safety incidents but the learning was not always effectively shared. Patient safety incidents were generally managed effectively to support shared learning in the diagnostic imaging department. The governance team supported the imaging manager to investigate incidents and produced learning summaries with actions to improve and prevent a re-occurrence. Following our inspection, hospital leaders provided us with learning summaries from 5 incidents where there was learning for the diagnostic imaging team. Hospital leaders told us learning summaries were shared with staff to promote learning. However, we did not see evidence of this during our inspection and most staff did not know where to access learning following incidents. Furthermore, at the time of our inspection, there was no consistent meeting structure within the diagnostic imaging department to facilitate shared learning, and most staff in the department were unaware of how to access or apply learning from incidents. Following our inspection, the service reinstated imaging governance meetings and demonstrated that learning was being shared; most staff spoken with after this could describe recent learning. For example, learning from a recent extravacsation incident.

Lessons had been learnt from safety incidents that occurred elsewhere and resulted in changes to improve care for others. For example, we saw evidence of assessment documentation being revised in relation to a wrong site injection never event occurring at a different site. This reduced the risk of staff carrying out a wrong site injection. Whilst this learning had been implemented, not all staff knew it was in response to a never event that had occurred.

Most staff understood the duty of candour; however, we reviewed an incident where professional duty of candour had not been carried out following a patient safety incident. This was later identified and carried out during the investigation. Learning had been shared about the importance of carrying out professional as well as statutory duty of candour.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Safety and continuity of care was a priority from referral through to completion of the diagnostic pathway. Referrals were accepted only from authorised referrers in line with IR(ME)R requirements, with systems in place to identify and escalate any unapproved requests. All referrals were screened for completeness and clinical appropriateness to ensure patients received safe care and the correct investigation.

Clear admission criteria supported safe delivery of care within the service’s scope. Patients were appropriately assessed prior to imaging, including completion of safety questionnaires and clinical review to identify and mitigate risks. Staff escalated concerns where required and worked collaboratively with referrers and radiologists.

Staff consistently followed nationally recognised safety processes, including use of the ‘pause and check’ tool, to confirm the correct patient, procedure and modality. We observed staff carrying out these checks and documenting the outcome. Pause and check audits were carried out by the service from October 2025 to March 2026 which showed 100% compliance with standards.

Staff carried out risk assessments collaboratively with each patient. Patients completed safety questionnaires upon arrival to identify any potential risks undergoing specific diagnostic imaging procedures. For example, the magnetic resonance imaging (MRI) safety questionnaire asked whether a pacemaker or prosthesis was present, or if they were pregnant. For patients attending for a computerised tomography (CT) with contrast, risks such as allergies and kidney function were assessed. Staff reviewed the patient responses prior to the procedure. Records we reviewed demonstrated a safety questionnaire had been completed and reviewed by staff. We saw evidence of specific risks being discussed with referrers and or radiologists before proceeding.

Staff took action to mitigate risks identified. For example, gowns were available for patients to change if their clothing contained metal, such as metal zips. Ear protectors were provided to patients. Staff had completed handling and moving training to safely manage patients’ requiring assistance to transfer to the scanning trolleys.

Safety was a priority for patients whilst in the department and during the diagnostic procedure. Radiation exposure was confirmed through a justification process prior to the scanning appointment. This meant patients were not unnecessarily exposed to radiation and the correct scan was carried out to avoid the need for further exposure. Staff ensured doses of radiation used for specific procedures for all patients were as low as reasonably achievable.

Local rules were not available in all imaging suites at the time of our inspection and had not been updated to reflect departmental changes. The service took immediate action to address this and during our follow up assessment on 18 May 2026, we observed the local rules had been updated and were easily accessible and on display in each imaging suite across the department. Local rules identified risks, including steps taken by staff to ensure scanning procedures were completed safely. For example, the service had local rules and employers’ procedures in place to protect staff and patients from ionising radiation.

Urgent and unexpected findings were appropriately recognised and escalated in a timely way, with effective communication to referrers or alternative clinicians to support prompt follow-up. An urgent findings policy was available for staff to refer to, and we saw evidence of staff escalating findings to referrers, consultants and requesting urgent review of the images by radiologists.

Systems were in place to respond to patient deterioration, including access to emergency equipment and trained staff. All diagnostic imaging staff were trained in basic life support techniques and in managing allergic reactions. Staff had access to a radiologist, consultants in outpatients and the resident medical officer (RMO). The Hospital had a resuscitation team who were trained in advance life support. A daily resuscitation huddle was held by the team each morning at 8.30am where emergency alarm checks were made and roles were allocated for the team in the event of an emergency.

Simulation training supported staff preparedness for emergencies and safe MRI suite evacuation. These were successfully carried out in December 2025 and May 2026.

Patient records were maintained securely, with reliable access to electronic systems. There were effective processes to support continuity of care, including timely sharing of information with GPs and other providers when care was transferred.

Care and support was planned and organised with people, together with partners to ensure continuity. When overall responsibility for the care and treatment of a patient moved to a different service provider, there was effective communication, which allowed for seamless transfer. Staff shared key information to keep patients safe when handing over their care to others. Staff copied letters to other professionals including colleagues involved in the care of patients, and to the patients’ GP to ensure key information was shared.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on 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. Training records showed all staff had completed safeguarding adult and children level 3 and preventing radicalisation training. There were current safeguarding policies, and these reflected the national guidance for adults and children, including where children were visitors.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff. Staff knew how to contact them. There was a named nurse for adult and child safeguarding. They had undertaken training at level 4.

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.

The registered manager had oversight of safeguarding within the service. Data provided showed from April 2025 to March 2026, the diagnostic service had not identified any concerns or made a safeguarding referral.

Staff followed safe procedures for visitors attending the diagnostic department. The service had an up-to-date chaperone policy, which all patients were informed of when they attended the service. Chaperone signs were visible throughout the department.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patient to do the things that mattered to them.

Patients were informed about the risks associated with diagnostic imaging procedures and how to keep themselves safe. Modality specific information leaflets were given to patients before the appointment. They contained information about the procedure, the risks and provided clear instructions to patients and their family or companions about how to minimise risks prior to attending and during their appointment. For example, patients were advised of the risks of having any MRI unsafe equipment and clothing on them. It also contained key information about how to prepare for a procedure before the appointment if required.

Patients were advised of how their test results would be communicated to the refer and when they should expect to receive their results following their examination.

Staff assessed patient risks to ensure they were safe to have the procedure they were booked in for. Staff had a comprehensive understanding of specific risks for each modality. They assessed risks such as allergies, renal function, pregnancy status, medical history, previous reactions, whether implants or pacemakers were present and recent radiation exposure. Modality specific safety questionnaires were used to assess these risks.

There were multiple signs around the department displaying risk information. For example, there were signs prompting patients to inform staff if they were pregnant.

Staff checked whether patients had any MRI unsafe equipment and clothing on them. Gowns were provided to patients to reduce this risk for patients undergoing MRI.

All records we reviewed demonstrated patients had completed safety questionnaires and they were reviewed with staff. Where risks were identified, staff took action to mitigate the risk.

Staff were skilled in identifying patients with anxiety or displaying challenging behaviour. They managed this in a positive way that protected their rights and dignity. Where possible staff planned and made sure the team knew about patients who needed additional support and put a plan in place to manage them. For example, they were provided extra time to ensure they felt safe and comfortable. Staff described how they took time to explain the procedures and provided opportunities to visit beforehand. Staff told us they could access the psychology team who could support patients’ mental health when required. The service also had access to the hospital mental health first aiders. These staff were identified each day at hospital wide meetings which were attended by the imaging manager, so staff knew who to access in an emergency.

All 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.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not always make sure equipment, facilities and technology supported the delivery of safe care or that there was appropriate mitigation of the risk.

The environment largely followed national guidance and supported safe care; however, not all risks were consistently managed. Diagnostic imaging services were located on the ground floor and included MRI, CT, ultrasound, fluoroscopy and X-ray, with mammography located separately in the breast service. Areas were generally spacious, accessible and well maintained, with appropriate waiting areas, changing facilities and secure access controls where required. Clear signage supported patient flow and safety. Patients were asked to wait in the waiting area until they were called through to the relevant diagnostic imaging suite.

The department had appropriate flooring, fire safety equipment and clear fire exits. Radiation areas were clearly marked with warning lights and restricted access controls. However, arrangements within the MRI suite did not always meet best practice. At the time of our inspection, warning signage, authorised access lists and safety information were not consistently displayed in line with the medicines and healthcare products regulatory agency (MHRA) best practice. Equipment labelling to indicate magnetic resonance (MR) safety status was not visible on equipment including a fire extinguisher and weighing scales. Some safety checks, such as oxygen supply servicing, had not been carried out within required timeframes. Managers told us they did not use the oxygen supply; however, it was functional and there were no visible safeguards in place to prevent staff from using it. Leaders took prompt action to address these concerns following our inspection. During our follow up inspection on 18 May 2026, we found significant improvements had been made. MRI safety signage had been appropriately displayed on the door and floor, safety belts were installed to prevent unauthorised access, the oxygen tap had been capped off and there was an up-to-date authorised access list on display. A 5-gauss line plan diagram was marked on the floor within the MRI suite to demonstrate the perimeter of the magnetic field, outside of which is considered a safe level of exposure.

Systems to ensure equipment safety were not always consistently implemented. Quality assurance (QA) processes were in place but had not been carried out for all equipment, and monitoring of ageing equipment was insufficient. Data provided following our inspection showed there had not been QA carried out for fluoroscopy and the mobile imaging machine in 2026. The service took immediate action by arranging for an external provider to carry out training on specific equipment to ensure staff were competent to carry out QA. During our follow up inspection, we observed QA had been carried out for all machines and a radiographer had been identified to ensure effective oversight of QA moving forward.

The mammography machine had been on the service risk register, and concerns had been raised at the radiation protection committee in April 2025 by radiologists about image quality. Following our inspection, the service told us radiologists approved all mammography scans after they had been performed to ensure they remained of acceptable quality. Whilst these checks were in place at the point of reporting, there was no evidence the service routinely carried out a programme of diagnostic image quality audits for further assurance of safety. Senior managers suspended the mammography service following our inspection as they wanted additional assurance the equipment was safe to use.

Lead aprons were available and used by staff when needed. We observed the aprons were in good condition to ensure staff were protected from radiation exposure. Annual checks of aprons to ensure they were not damaged, were not consistently carried out in line with the provider guidance. The last audit was in April 2024. However, an audit of aprons was carried out immediately following our initial inspection and we saw this had been completed during our follow up inspection on 18 May 2026.

Not all staff working with ionizing radiation wore personal radiation monitoring badges. However, during our follow-up inspection, we observed all relevant staff wearing badges. Furthermore, systems to monitor staff radiation dose levels who worked across sites had been implemented to ensure safe monitoring of temporary staff.

The service had a health and safety executive (HSE) registration certificate for use of ionising radiation, which they provided us following the inspection.

Servicing and maintenance of the premises and equipment was carried out using a planned preventative maintenance (PPM) programme. The service completed PPM checks regularly and in line with manufacturer’s guidelines, which included checks by medical physics experts and were replicated in each modality. Diagnostic imaging equipment used at the hospital was serviced regularly as required and maintained by a recognised service team. We saw evidence that equipment had the necessary acceptance checks and critical examination reports to demonstrate the outcome of testing safety features and warning devices.

There was a system to ensure repairs to broken equipment were carried out quickly, so patients did not experience delays. Staff told us they had a good relationship with the external provider and when contacted, they were onsite the same or next day to complete repairs.

We checked consumable equipment and found all single use items were in date.

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. The MRI scanners were fitted with emergency buttons which stopped scanning and switched off power to the magnet.

Emergency equipment was located within the imaging department. Equipment was safely stored on the trolley, it was fully stocked and in date, and ready for use in an emergency. Regular checks of emergency equipment was carried out by staff. It was accessible for all diagnostic modalities. An MRI safe trolley and transfer board had been located within the MRI scanning room to improve speed of evacuation. An emergency grab bag was available in the breast screening service.

Anaphylaxis emergency boxes were accessible and located throughout the department. They contained equipment and medicines required to manage an allergic reaction to contrast medium. All staff had received training to manage an emergency and allergic reactions.

Patients could summon assistance and help as needed during their scan and we saw how patients were shown this. Patients could reach call bells and staff responded quickly when called. Emergency pull cords were available in areas where patients were left alone, such as toilets, and emergency call buzzers were available within the MRI and CT scanning rooms to alert staff. Microphones were built into the scanners to enable 2-way communication between the radiographer and the patient.

Staff disposed of clinical waste safely. Waste was segregated and labelled in accordance with the provider policy. Sharps bins were labelled; the bins were not overfilled and were closed when not in use. Waste bins for recyclable waste were also in place. Hazardous substances were stored safely and information about products was available to staff.

The service did not always make sure there were enough qualified, skilled and experienced staff. Managers did not always make sure staff received effective support, supervision and development. However, staff worked together well to provide safe care that met patient’s individual needs.

The service provided mandatory training in key skills, but they did not ensure all staff had completed it. Data provided to us following our site visit showed the 95% compliance target was met in 17 out of 28 modules with an overall compliance rate of 86%. Staff had been given a deadline to complete outstanding modules by the end of May 2026. Furthermore, not all staff had been trained to enable them to carry out essential diagnostic equipment safety checks. However, all relevant staff had completed training on recognising and responding to patients with mental health needs, learning disabilities and dementia. Radiologists worked for the hospital under practising privileges and did not receive mandatory training from the service. They received training from their substantive NHS employer, and the hospital had oversight of their completed training records.

The service did not always have sufficient numbers of suitably skilled staff to keep patients safe and meet demand. For example, some diagnostic modalities including MRI relied on the service manager to cover shifts as the department was not up to full establishment. This meant the manager did not have full oversight of the service and was not always able to effectively carry out managerial tasks. A radiographer had been recently recruited with a planned start date in May 2026. Staff included 1 whole time equivalent (WTE) imaging manager, 6 WTE specialist radiographers, 0.4 WTE imaging assistants and 1.8 WTE administrative staff. The service had 12 bank radiographers who were used based on the demands of the service. Where needed, bank staff were used to maintain safe staffing levels. However, the service struggled to secure bank staff with right skills to ensure the service was staffed appropriately. For example, there were limited staff able to carry out mammography and MRI scans. Following our inspection, leaders strengthened staffing resilience by increasing bank support and enabling the imaging manager to focus on managerial responsibilities which they had been unable to do since commencing in their role in January 2026.

Staffing levels and skill mix were planned using a recognised staffing tool, with appropriate oversight to ensure safe delivery of care across all imaging modalities. The staffing tool was updated daily and reviewed by the imaging manager and hospital leaders at daily hospital meetings. The staffing tool included a 24% uplift to ensure staff could carry out non-clinical duties. For example, completing mandatory training, carrying out audits and administrative duties.

Each modality was appropriately staffed, and staffing levels at the time of inspection reflected planned rotas. Most staff told us they felt there were enough colleagues to provide safe care and were able to take breaks. However, some staff raised concerns about lone working during on-call periods. Leaders had completed risk assessments and arrangements were in place to mitigate risks, including a sign in process and access to wider hospital support so staff did not have to lone work. Additional administrative support was being introduced to strengthen out-of-hours provision.

Patients 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 was sufficient staffing.

The service did not employ any medical staff. Sixteen 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.

Managers did not always make sure staff attended team meetings or had access to important information. However, following our inspection, the service re-introduced quarterly team meetings and daily huddles where staffing levels were discussed and key information was shared with staff. We observed these had been embedded during our follow up inspection.

New staff received an induction to the service and their role. Temporary bank workers had a local induction to the area in which they were working. 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 them.

Managers supported staff to develop through constructive recorded, annual appraisals of their work. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement. The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. For example, we found staff only worked in imaging modalities with the correct competencies. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, the service had given staff time to complete QA training to enable them to carry out safety checks of equipment.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading. There were examples of poor practice which increased the risk to patients.

The service did not always manage infection risks well. We found some equipment was damaged which meant the service could not be assured the equipment was adequately cleaned to prevent the risk of infection. For example, the mammography machine plates were chipped, a trolley used to prepare injections had significant and visible dirt build up and rusting, and some MRI cushions were damaged. The senior management team took immediate action to reduce this risk following our inspection. During our follow up inspection, we found there was new MRI cushioning and a new ultrasound trolley being used. There was a plan to replace the mammography plates should the service be resumed.

Staff used equipment and control measures to protect patients, themselves, and others from infection. They generally kept equipment and the premises visibly clean. Each diagnostic modality had a cleaning schedule in place which showed each area underwent regular cleaning. Most diagnostic suites and control rooms were visibly clean and tidy. However, the MRI control room had some dust build up and some packaging from syringes and medicines had not been disposed off.

Staff told us they cleaned equipment after patient contact. However, they did not label equipment to show when it had last been cleaned.

We observed staff followed best practice guidance for the routine disinfection of ultrasound equipment (European Society of Radiology Ultrasound Working Group, Infection prevention and control in ultrasound– best practice recommendations from the European Society of Radiology Ultrasound Working Group (2017)). The ultrasound probes were decontaminated using 3 step disinfectant wipes between each patient and at the end of each day. This was routinely documented in decontamination record books for each probe.

The department as a whole was visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. For example, waiting rooms, toilets and patient changing areas were clean.

Staff followed infection, prevention and control (ICP) principles including the use personal protective equipment (PPE). We saw staff wearing gloves for all patient contacts and they routinely sanitised their hands using either hand gel or handwashing facilities. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

Staff understood the process for managing spillage of body fluids in the department. There were spill kits for bodily fluids and toxic waste safely stored in the department.

There were processes to enable staff to respond to ICP risks such as transmittable infections. Longer appointment times were provided for patient with a known infection to ensure appropriate deep cleaning and they were often at the end of the clinic.

There was a provider IPC policy and supporting guidance. This had been reviewed and was accessible for staff to access when required.

There was a programme of ICP audits including for example, national standards for Hospital cleanliness, aseptic non-touch technique, hand hygiene, sharps and standard ICP practice. The service performed well in local IPC audits. In the most recent audits carried out from October 2025 to March 2026, the scores showed 99-100% compliance with infection prevention and control measures. However, we were not assured these audits were always effectively carried out as they did not identify the ICP risks we found during our inspection.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff did not always involve patient in planning.

Patient Group Directions (PGDs) were used to administer contrast medicines for MRIs and CT scans. However, they had not been appropriately authorised in line with guidance. PGDs provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber). At the time of our inspection, PGDs were being used to administer contrast media medicines such as gadoteric acid and iohexol to carry out a contrast MRI or CT. Contrast media is a substance introduced into a part of the body to improve the visibility of internal structures during radiography. However, the PGDs had not been appropriately authorised, and staff had not signed to confirm their understanding of and adherence to the PGD. This meant there was a risk medicines were not being used within a safe framework. We escalated this to the Spire imaging lead who immediately removed the PGDs and a decision was taken to temporarily suspend contrast MRI and CTs clinics.

Following our inspection, the service reviewed the PGDs, ensured they had been appropriately authorised, and staff had signed to acknowledge they understood and would adhere to the PGD. Staff had undergone a competency assessment. Staff had been trained on the safe administration of contrast media through a competency assessment carried out immediately following our inspection. During our follow up assessment, staff administering contrast had confirmed they had received training and knew about the PGD updates. The clinics had restarted following staff competency assessment had been carried out.

Oversight and governance of medicines were not always effective. For example, we asked the service to send its most recent PGD audit which showed 100% compliance with PGD standards. Based on what we found during our inspection, we were not assured the audits were effective in identifying non-compliance.

Medicines were safely stored. Staff had access to the required medicines which were stored in a locked cupboard. The keys were located in a key safe. Medicines requiring storage within a designated room were stored at the correct temperatures, in line with the manufacturers’ recommendations, to ensure they would be fit for use. Room temperatures were recorded as part of the daily checks by staff. Staff knew what to do if the temperatures were not within the required range. Contrast media was stored appropriately and was accessible to trained members of staff.

Medicine cupboards were clean and tidy. During our inspection, we checked the medicines in the cupboard, and all were within their stated expiry date.

The service did not store or administer controlled drugs.

Emergency medicines were stored on the emergency trolley within the department. Each area had an anaphylactic box which staff told us they had been trained to use. All emergency drugs were within their expiry date.

Allergies were clearly documented on referral forms and safety questionnaires. Allergies were verbally checked during the diagnostic imaging safety checklist. From April 2025 to March 2026 1 allergic reaction to contrast had been reported with no harm.