Queen Square Imaging Centre

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 had systems and processes in place to support the delivery of safe care. The environment was visibly clean and well maintained, with appropriate infection prevention and control (IPC) measures in place. Cleaning logs were maintained, and staff adhered to personal protective equipment (PPE) and hand hygiene protocols. However, the cupboard where products classified under Control of Substances Hazardous to Health (COSHH) regulations and medicines board were found unlocked during the assessment, which was not in line with safety regulations.

Staffing levels were appropriate for the service’s activity. Radiologists worked under practising privileges and were drawn from the National Hospital for Neurology and Neurosurgery. While the provider relied on the NHS trust to conduct DBS checks and training for radiologists, it did not hold direct evidence of compliance, which limited assurance.

Fire safety procedures required improvement. The evacuation plan included a fire exit that was locked and lacked appropriate signage, leading to confusion among staff about its use in an emergency.

The service had protocols for emergency response situations, including crash team support. Equipment safety was generally well managed, with daily checks of the resuscitation trolley and contrast storage temperatures. Staff maintained competencies through annual reviews, and all radiographers were trained in both MRI and CT modalities.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had systems in place to support a learning culture, with evidence of incident management, audit activity, and staff engagement.

The service demonstrated a structured and proactive approach to incident reporting and organisational learning. Staff used an electronic system to log and track incidents, which were reviewed monthly by the operations manager and discussed at the Quality, Safety and Clinical Risk Management (QSCRM) group. Incidents were also displayed on the MRI noticeboard to support shared learning. Staff confirmed that no serious incidents occurred in the previous 12 months, and minor incidents were managed appropriately with documented follow-up actions.

Staff described a culture of openness and accessibility, with leaders encouraging feedback and supporting staff to raise concerns. Learning from incidents was cascaded through team meetings and governance forums. The service had emergency response protocols, including the use of the crash team from the local NHS trust. Staff participated in regular drills and a recent simulation exercise. While these systems were well established, some staff interviewed during the inspection expressed uncertainty about specific roles in evacuation scenarios.

The service maintained a risk register, reviewed biannually, and used an electronic system to track operational and organisational risks. During the assessment we noted some risks had been present for extended periods; the provider has clarified this reflects deliberate retention of well‑controlled residual risks rather than lack of action.

Audit findings were used to inform practice, and the service had a comprehensive audit schedule aligned with Quality Standard for Imaging (QSI) and BS70000 standards, including monthly peer review of radiology reports and turnaround times.

The service had clear systems in place to manage imaging referrals, patient transitions, and clinical handovers. Staff accepted referrals via an electronic patient record system, email, or paper forms. All referrals required a valid imaging request. Staff did not accept self-referrals and redirected patients without a referral to appropriate clinicians. Local rules and employer’s procedures were reviewed and updated in line with the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) to ensure safe use of ionising radiation for CT.

Staff carried out safety screening before imaging. Patients completed safety forms independently, followed by a second review by staff to confirm understanding and identify any risks. Staff discussed the risks and benefits of contrast agents and provided written information. Where relevant, staff checked renal function and recorded findings in the patient record. Staff also confirmed consent and identification before imaging.

Staff received a monthly list of patients from a local NHS trust and staff scheduled appointments accordingly. There was no requirement to monitor referral-to-scan times or prioritise by urgency. Staff offered alternative dates, if patients could not attend, within three weeks if needed and contacted patients the day before to confirm attendance and make adjustments if required. Staff directed patients who required hoist support or additional support to the NHS trust.

Staff used integrated systems to support clinical handovers. Imaging and reports were shared securely with referring clinicians. Reporting was carried out by consultants working under practising privileges. Staff confirmed that reporting turnaround times were monitored internally. However, assurance around external reporting was limited, and the service had identified this as an area for improvement.

Audit records showed that imaging protocols were reviewed annually. Staff carried out dose optimisation and maintained diagnostic reference levels. The service had completed a patient dose survey and environmental monitoring. Staff used a structured system to record and review risks, and governance meetings included discussion of audit findings and safety processes.

The service had systems in place to safeguard adults and respond to concerns. Staff had access to a safeguarding policy and were aware of how to escalate concerns. The service had appointed a safeguarding lead trained to level 3 in adult and child protection, and staff confirmed they could access safeguarding support through the local NHS trust. A safeguarding contact list was available on-site, and staff were aware of the named leads.

Staff completed mandatory safeguarding training appropriate to their roles. Training records showed that all staff had completed level 2 safeguarding training for adults and children. The service maintained a training matrix and monitored compliance through governance meetings.

The service did not provide imaging for children. However, children could attend the site as visitors. The service issued appointment letters advising patients that children must be accompanied by another adult and that the service could not take responsibility for them. Staff confirmed that any imaging for children was redirected to another site managed by the provider, where appropriate safeguarding arrangements were in place.

The service had a dementia awareness folder and used a dementia assessment template to support staff in identifying and responding to cognitive needs. Staff were aware of their responsibilities under the Mental Capacity Act and told us how they would assess capacity and escalate concerns. The consent policy included guidance on assessing capacity and acting in a person’s best interests.

Staff involved patients in managing risks associated with diagnostic imaging procedures. Patients completed safety screening forms prior to MRI scans, which included questions about implants, allergies, claustrophobia, and other individual risk factors. Staff reviewed these forms with patients to confirm understanding and identify any contraindications. Patients were given the opportunity to ask questions and were informed of safety procedures.

Staff adapted procedures to meet individual needs. Patients who experienced anxiety or claustrophobia were supported with additional time, reassurance, and adjustments to the scanning process. Patients could bring a supporter into the MRI scan room, subject to satisfactory completion of safety screening.

For both, CT and MRI, staff confirmed that patients were informed about the risks and benefits of procedure and were given time to consider options. In particular, staff confirmed that risks were discussed with patients prior to procedures involving contrast media with written information on risks involved with use of contrast agents. Patients were also advised on what to do in the event of a delayed reaction.

Where relevant, renal function was checked and recorded. Staff also confirmed that patients were informed about the risks and benefits of procedures and were given time to consider their options.

The service operated from a well-maintained clinical environment that supported the safe care and treatment of patients. Clinical areas, including the MRI and CT control rooms, were routinely cleaned by in-house staff, while communal and non-clinical spaces were managed by an external cleaning provider. Daily cleaning logs were in use. The flooring throughout the department was compliant with hospital specifications, with vinyl surfaces and rounded edges to aid infection prevention.

MRI and CT safety measures were in place and generally well maintained. MRI entry doors were fitted with interlocks to prevent scan sequences from continuing if opened, and a 3.0T magnetic warning sign was prominently displayed. A boundary around an MRI scanner that marks the area where the magnetic field strength reaches elevated level (5 Gauss line diagram) was clearly shown within the scan room. However, the hazard belt used to block off the MRI scan room door was not consistently used, and the attachment point was damaged, though still functional. This was flagged for repair. After the assessment, the provider told us the hazard belt at the entry of the MR controlled access area had been replaced.

Site-specific safety procedures and operational guidelines that governed the use of MRI and CT equipment, known as local rules, were available and within review. Named safety personnel were in place, including a magnetic resonance safety expert, radiation protection advisor, and medical physics experts. Control of Electromagnetic Fields at Work Regulations 2016 guidance was referenced but lacked practical advice for staff on limiting exposure to magnetic fields.

Emergency preparedness was robust. A resuscitation trolley was checked daily, with intact tags and records of monthly audits. A hypoglycaemia kit was available with updated guidelines, and an MRI-compatible fire extinguisher was present and in-date. Emergency door release buttons were installed where appropriate, and oxygen and helium levels were monitored with alerts coordinated through the equipment supplier.

Portable electrical appliances were tested and appropriately labelled to demonstrate ongoing safety monitoring. Although the premises and core facilities were the responsibility of the NHS trust under a service level agreement, the provider had commissioned an external fire safety risk assessment to obtain independent assurance, given their limited access to the trust's internal assessments. In addition, staff carried out daily water flushing of taps as part of routine water safety checks, intended to prevent stagnation and reduce the risk of Legionella contamination.

Access and safety signage were mostly compliant. Entry to the MRI lobby was restricted via swipe/code access. However, a pregnancy warning sign was missing in one cubicle, and weighing scales were not medical-grade or calibrated. In addition, an emergency exit door located near the MRI area was marked as an evacuation route on the fire escape plan, but it was kept locked, with staff indicating it was not in use for evacuation. Additionally, there was no directional signage leading to this door, which posed a risk of staff or patients becoming trapped in the event of a fire blocking the main exit route. After the assessment, the provider told us medical-grade and calibrated patient weight and height scales had been ordered and were now in use. The provider also told us the controlled area exit door had its fire exit designation removed following review with the local NHS trust’s fire officer, and the fire escape plan was updated to reflect this change

The service maintained a current risk register and had completed relevant risk assessments, including for health and safety, COSHH. However, the COSHH cupboard was found unlocked during the assessment.

The service was safely staffed with a mix of full-time radiographers, a superintendent radiographer, and administrative personnel including booking coordinators and reception staff. Radiologists worked under practising privileges arrangements, primarily drawn from the local NHS trust. These radiologists were part of the trust rota and included both neuro and non-neuro specialists, with neuroradiologists present for each clinical session and a duty radiologist available at weekends. However, the service did not hold direct evidence of mandatory training, safeguarding training, or DBS checks for doctors working under practising privileges, relying solely on oversight from the NHS trust. This meant they had limited assurance of compliance with statutory requirements.

Competency tracking was well established for employed staff. There was evidence of ongoing assessment compliance for all radiographic staff across both MRI and CT modalities. All radiographers were trained in dual modality, and there was evidence of site-specific competencies such as MR-guided procedures, contrast administration, anaphylaxis management, and equipment handling. Cannulation competencies were maintained and reviewed annually.

There were sufficient staffing levels that met demand, with managers able to provide cover for sickness or leave. Rostered radiologists ensured consistent oversight, including weekend sessions. There was evidence of staff engagement and development, with routine meetings taking place, and action plans tracked from those discussions. Staff training compliance amongst employed staff members was good, with records showing 100% completion across mandatory areas.

The service did not use agency or bank staff.

The environment was visibly clean and well maintained. Clinical areas such as the MRI and CT rooms were cleaned by staff, while all non-clinical areas were attended to daily by an external cleaning contractor. There were appropriate cleaning logs in place, including daily records for control areas.

Hand hygiene facilities were readily available, and staff had access to personal protective equipment (PPE) such as gloves and masks. Staff adhered to standard IPC protocols, including the use of PPE and hand hygiene practices. Alcohol gel dispensers were available throughout the department, and staff were observed using them appropriately. Waste disposal was managed in line with clinical guidelines, with separate bins for general and clinical waste, and sharps containers were correctly labelled and not overfilled.

Spill kits were available in clinical areas, and infection control materials such as disinfectants and wipes were stocked and in use. Regular audits supported assurance processes for cleanliness and infection control.

An infection control audit tool was used by the service to assess compliance with cleanliness and hygiene standards. The most recent audit was conducted in February 2025 by the superintendent radiographer. This covered a broad range of clinical and non-clinical areas, including bathroom facilities, cleaning cupboards, clinical rooms, staff rooms, and preparation areas. The audit evaluated the physical condition of the environment to ensure it was well maintained and reduced the risk of cross-infection. Checks included the presence of dust on high horizontal surfaces, condition of furniture, cleanliness of window coverings, and the state of extractor fans. It highlighted minor gaps in compliance with handwashing and linen handling standards. An action plan was developed with two identified areas for improvement, and both actions had been completed at the time of our visit.

Medicines and contrast media were generally stored securely and appropriately managed, with temperature-monitored conditions in place for agents such as Dotarem and Clariscan. Controlled drugs were not held on site and not in use.

A medical fridge used for storage was checked daily, with temperature ranges monitored and recorded, and alert systems in place for deviations.

Patient group directions (PGDs) covering injectable contrast agents and other relevant substances were valid and up to date, with review dates extending to 2027. PGD is a written instruction that allows authorised health professionals to supply and/or administer a medicine to a specific group of patients without needing a prescription or patient-specific direction.

Staff followed safe administration procedures, including a two-person check before contrast media were given to patients. The Radiographic Department Assistant maintained monthly stock checks to ensure oversight, and all drugs reviewed were in date and clearly labelled.

However, during the visit, a medicines cupboard was found left unlocked in a corridor area used by patients for changing. Although this area was not openly accessible to the public, the unsecured storage posed a risk of unauthorised access and did not align with best practice for medicines security. Staff acknowledged this and committed to reviewing their procedures.