Queen Square Imaging Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service was well-led, with clear strategic direction, visible leadership and a culture of openness and collaboration. Staff described the management team as approachable and supportive, and there was evidence of regular communication, structured governance, and a commitment to continuous improvement.

The provider had embedded systems for risk management, audit, and staff development, and maintained strong links with the local NHS trust. While some governance processes were informal, the service demonstrated accountability and responsiveness to feedback. Managers encouraged staff to raise concerns and contribute to service development, and there was a shared understanding of the service’s purpose and values.

This service scored 68 (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 operated with a clear mission, focused on delivering high-quality neuroimaging service and reinvesting surplus income into NHS services. Staff were aware of the provider’s not-for-profit model and described a shared commitment to patient care and service excellence. The provider documented their strategic objectives in the business plan and reflected in operational priorities, including investment in new imaging technologies and expansion of service capacity.

The service held team meetings regularly, and staff reported feeling informed and involved. Staff described the culture as inclusive and improvement-focused, with low turnover and strong peer support. Staff demonstrated pride in their work and alignment with the service’s values, which were reflected in day-to-day practice.

Leadership was visible and effective. The registered manager, who also served as the chief executive officer, was present on site and actively engaged with staff. The superintendent radiographer provided clinical leadership and oversaw staff development, appraisals, and operational delivery. Staff described leaders as approachable, responsive, and committed to supporting the team.

Leadership roles were clearly defined, and responsibilities were distributed across clinical and administrative functions. Staff reported that managers supported wellbeing, training and accountability, and there was evidence of leadership development through attendance at external conferences and study days. Equality and inclusion were promoted through fair recruitment, flexible working, and access to development opportunities.

Staff were encouraged to raise concerns and contribute to service improvement. Regular team meetings provided a forum for discussion, and staff described a culture of openness and psychological safety. While a formal Freedom to Speak Up Guardian was not in place, staff were aware of how to escalate concerns and felt confident doing so.

Staff were involved in identifying risks and suggesting improvements, and there was evidence of feedback being acted upon.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had governance structures in place, including a clinical governance policy, a business continuity plan, and a structured audit schedule aligned with QSI standards. Governance meetings were held regularly, and minutes showed that incidents, complaints, and audit findings were discussed. The provider maintained a risk register and had systems for tracking actions and reviewing risks. However, while these frameworks were in place, there were gaps in implementation and assurance, particularly in relation to medical staff governance.

There was no local oversight of mandatory training compliance nor DBS checks, for doctors working under practising privileges. The provider relied on the assumption that the local NHS trust, which employed the radiologists, completed all required training and DBS checks every three years. However, there was no formal mechanism in place to verify this or to maintain a register of DBS status. The practising privileges documentation stated that consultants were required to have up-to-date training and DBS clearance, but the service did not hold or routinely review evidence to confirm compliance. The only assurance available was through appraisal documentation, which included a general statement about training and safeguarding, but did not specify dates or content of completed training.

This lack of direct oversight meant the provider could not demonstrate that all doctors working on site had current and appropriate safeguarding training or DBS clearance, which posed a risk to safe and compliant service delivery. The absence of a robust system for monitoring these requirements indicated a weakness in governance and risk management.

In addition, while the service had a risk register and used an electronic system to monitor risks, several risks had been present on the register for extended periods (up to 6 years). The provider explained that some of these were inherent or residual risks that remain visible on the register by design and had been assigned a ‘stable risk’ status. However, at the time of the assessment, inspectors did not receive consistent explanations that demonstrated how the rationale for retaining long‑standing risks, and the associated oversight, accountability and mitigation arrangements, were being actively managed.

Issues related to fire safety signage and evacuation routes had not been identified as a risk at the time of assessment. Staff expressed confusion about the designated fire escape route, and the evacuation plan did not reflect the physical layout or access limitations of the building. Although the provider had commissioned an external fire risk assessment due to delays in obtaining documentation from the NHS trust, the findings had not identified the escape routes being wrongly marked.

The service had achieved QSI accreditation and was subject to external quality assurance, including annual reassessments. However, some governance processes remained informal or underdeveloped. For instance, while audit activity was taking place, there was limited evidence of systematic clinical audit or peer review of radiology reports.

Despite these gaps, staff described a supportive leadership culture, and there was evidence of regular team meetings, clear communication, and a commitment to continuous improvement. The provider had invested in new imaging technologies and maintained financial sustainability through its not-for-profit model.

The service maintained strong partnerships with the local NHS trust, including shared electronic records systems, clinical oversight, and access to emergency support. Radiologists worked under practising privileges and were part of the trust rota, ensuring continuity of care and integration with wider clinical pathways.

The provider collaborated with external clinical consortiums and participated in national initiatives to reduce access to diagnostic waiting times. Patients were referred through established pathways, and the service coordinated with other sites to ensure timely access. While formal community engagement was limited, staff told us that they had good relationships with referring clinicians and NHS partners.

The service demonstrated a commitment to learning and innovation. Staff were supported to attend conferences, study days and continuing professional development (CPD) activities, and competencies were reviewed annually. The provider had implemented new imaging technologies, including MRI-guided focused ultrasound and AI-based reconstruction tools, to improve image quality and reduce scan times.

Audit activity was structured and aligned with QSI standards, covering reporting turnaround, IR(ME)R compliance, and administrative processes. Findings were reviewed in governance meetings and used to inform service improvements. Staff were involved in identifying learning needs and contributing to service development, and there was evidence of continuous improvement through feedback, audit, and risk review.