HCA Healthcare UK The Harborne 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients in the department. People received treatment and care to reduce the risk of avoidable harm, which included following safety standards related to exposure to radiation and safety checks prior to entering the MRI. There were safety processes arranged before procedures started, with staff working together to ensure the right patient had the correct imaging. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

This is the first assessment for this Diagnostic Imaging service. This key question has been rated good. Patients were 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. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

People were able to raise concerns and report incidents. The service had systems in place for recording safety incidents through an electronic incident reporting tool. Concerns and incident reports were taken seriously, investigated appropriately, and learning was shared with colleagues.

In the 12 months prior to the assessment, there had been 1 incident reported to the Care Quality Commission, which occurred in June 2025. There were no incidents reported to the Health and Safety Executive (HSE) during this period.

The diagnostic imaging service had processes in place to investigate incidents, identify learning, and share this with staff. During our review of a sample of recent incidents related to diagnostic imaging, all of which were classified as ‘no harm’, we found that appropriate reviews had been undertaken and actions implemented in a timely manner.

Staff we interviewed were confident in identifying and reporting incidents in line with the service’s incident reporting policy, particularly in relation to radiation-related incidents, which were escalated to the Radiation Protection Adviser where appropriate.

Staff told us they received individual feedback on incidents they had reported. The provider’s summary of recent incidents also stated that managers would speak directly with staff involved to support reflection and learning following incidents.

Learning from incidents was also shared through daily huddles, team emails, and staff newsletters.

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.

Radiologists told us that serious or unexpected findings were uncommon. However, when significant or abnormal findings were identified, there was a process of escalation in place for staff to follow, staff we spoke with understood the information was communicated promptly. Where immediate clinical action was required, staff could contact the duty doctor or urgent care service directly. Critical findings could be flagged through a separate electronic alert system to ensure the referring clinician was notified promptly.

The service offered same day booking for scans where capacity allowed. Patients who had attended a consultation and required diagnostic imaging could be booked for a scan on the same day. Consultants confirmed appointment availability with the imaging department before submitting a same-day referral, which was then reviewed and triaged by a radiologist prior to the scan being undertaken. This helped ensure imaging requests were clinically justified, the most appropriate modality was selected, and patients were prioritised according to clinical need.

Patients using the same-day service told us this was helpful, particularly for those who had travelled long distances or experienced heavy traffic in the local area.

Data showed the hospital and imaging department are a newly opened service, they are currently operating below their designed capacity. This results in gaps between scheduled patients, which also supports the walk‑in service. Consequently, patients are generally seen very quickly upon arrival, regardless of whether they are early or late for their allotted appointment time.

When patients arrived for their scan, they were asked to complete a safety questionnaire about their medical history and any potential risk factors relevant to the imaging procedure. Staff reviewed this information before the scan to ensure it was safe to proceed.

The service had a standard operating procedure in place and the purpose for this had been to establish the likelihood of pregnancy of a patient, before they undergo their procedure. This ensured that consideration is given to the foetus during the procedure.

The service had an inclusive pregnancy status (IPS) form which patients completed before their procedure took place, this clearly identified any risks to the patient and unborn baby.

Where patients had previously undergone imaging at another hospital, staff could request these images through the Image Exchange Portal. This supported continuity of care and helped reduce unnecessary repeat imaging.

Radiologists completed reports either at the time of the procedure or within the following few days. Reports were stored electronically and were accessible to referring clinicians to support ongoing patient care.

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.

During our assessment, all staff we spoke with, including agency staff, demonstrated an awareness of who the safeguarding lead was and understood how to escalate safeguarding concerns appropriately. Safeguarding information displayed signposted staff to support staff, they could refer to a list of departmental leads available within the department.

Staff received safeguarding training appropriate to their role on how to recognise and report abuse. Radiography staff were trained in both level 2 and level 3 safeguarding adults. Training compliance data provided by the service related to both diagnostic imaging and surgical staff. The combined data showed 100% compliance for safeguarding adults level 2 training and 88% compliance for safeguarding adults’ level 3 training. The data showed a combined 92% of staff had completed children’s safeguarding level 2. In addition, 96% of diagnostic imaging staff had completed mandatory training on learning disability and autism.

Patients we spoke with during the assessment told us they knew how to raise concerns if they felt unsafe or were worried about the safety of others. Patients said they would feel comfortable approaching any member of staff if they had an issue and reported feeling safe and well supported while attending the service.

Chaperones were available for patients if required. During the assessment we observed consultants and other members of staff ask patients if they would like a chaperone during their appointment.

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.

Staff attended a daily huddle at the start of each session to review the patient list and discuss any patient-related concerns. This also provided an opportunity for staff to highlight any capacity, staffing, or operational pressures that may impact the service and to plan the day’s activity accordingly.

The service used a safety checklist for individuals entering areas close to the MRI scanners. This checklist was completed before each patient examination to ensure it was safe to proceed. Carers and other individuals accompanying patients who needed to enter the scanning area were also screened to confirm it was safe for them to be present.

The service had a clear pregnancy procedure in place. Staff confirmed a patient’s pregnancy status before imaging procedures so that appropriate precautions could be taken to minimise radiation exposure.

Staff communicated with patients to ensure they understood their care and treatment. During the inspection we observed numerous procedures where staff explained the imaging process clearly to patients and checked their understanding before proceeding with the examination.

There was a process in place for managing medical emergencies within the MRI environment. Staff told us that all new starters, including those who did not routinely work within the department, were required to complete MRI safety training as part of their induction. This was to ensure staff understood the risks associated with the MRI environment and how to respond in an emergency. However, not all radiology staff, both bank and permanent, who had completed induction had signed to confirm that they had read and understood the Local Rules, which set out the radiation safety arrangements and safe working practices within the department.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

An external supplier was responsible for servicing and maintaining the diagnostic imaging equipment used by the hospital. The service schedule showed that all imaging equipment received regular servicing in line with maintenance requirements. Training for mammography equipment was provided directly by the supplier.

Staff carried out daily quality assurance checks on CT, MRI, X-ray and mammography equipment, with additional monthly quality assurance checks also undertaken. At the time of the assessment, quality assurance was supported by medical physics. Leaders told us there were plans to train radiographers to undertake some of these checks in-house in the future.

The resuscitation trolley was checked daily to ensure equipment was available and ready for use. Adult resuscitation policies were accessible to staff.

Imaging rooms were secure, with access controlled through digital locks. Rooms were visibly clean, tidy, and stocked with appropriate personal protective equipment. Radiation warning lights were displayed outside scanning rooms, and radiographers manually locked the doors while scans were in progress to prevent unauthorised entry. All X-ray rooms displayed appropriate signage reminding staff to check pregnancy status and identifying controlled access areas.

Staff told us that visibility in some sub-waiting areas could be limited when control room doors were closed. Leaders were aware of this and told us that inpatients were always escorted when attending the department, which helped mitigate potential risks. The service had identified this as a potential risk and it was on the service risk register. Leaders told us they were exploring the installation of a camera monitoring system to improve visibility in these areas and were working with the estates and finance teams to progress this.

Fire extinguishers were within their service dates. MRI equipment was clearly labelled, and equipment used in the vicinity of the MRI scanner had visible labels indicating whether it was MRI safe or unsafe. The department also had an MRI-safe wheelchair and trolley available to support the safe transfer and movement of patients within the MRI environment.

The provider supplied evidence demonstrating that occupational radiation exposure was monitored for staff, including monitoring related to the use of lead aprons.

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.

Staff and radiologists worked well together to provide safe care that met people’s individual needs. Staffing levels were reviewed daily during team huddles to ensure there were sufficient staff available to safely manage the service. The department ensured that 2 radiographers were available to support each scan. To cover breaks or periods of reduced staffing, the department manager and superintendent radiographer were trained to step in and provide additional support when required.

The service routinely used bank staff. Bank staff we spoke with during the assessment were aware of the incident reporting system and had completed safeguarding training. They told us they were satisfied with the induction process and felt they were given sufficient time to familiarisation with the department, and its processes and were well supported during their induction.

Leaders described robust governance processes for radiologist recruitment and practising privileges, which medical practitioners whom permissions are granted by independent hospitals to, allowing them to treat patients within the service without being directly employed. This included background checks, review and sign-off by relevant clinical leads, and approval through the Medical Advisory Committee.

At the time of our assessment, leaders recognised that demand for the imaging service was increasing and were in the process of recruiting 2 additional radiographers to support the growing department.

Compliance with staff appraisals was 100% at the time of our assessment. Staff told us they received regular appraisals which provided opportunities to discuss learning and development needs and said they were supported to attend study days.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

During the assessment we reviewed cleaning records for the period December 2025 to January 2026, which demonstrated 100% compliance with scheduled cleaning checks.

We observed staff following appropriate infection prevention and control (IPC) practices. This included the safe handling and disposal of sharps and other hazardous waste. A dedicated housekeeping team was responsible for maintaining cleanliness throughout the department. Good hand hygiene practices were evident and supported by regular training and auditing. Following the assessment, the provider submitted mandatory training data which showed that 96% of staff across the diagnostic imaging and surgery departments had completed IPC training.

Staff told us they were informed in advance by wards when patients with known infections were due to attend the department. These patients had a designated decontamination bin and infectious waste bags which accompanied them during their time in the hospital. The hospital had a designated infection control nurse who oversaw infection control arrangements and was made aware of patients with infectious conditions. Where possible, these patients were scheduled at the end of the scanning list or allocated longer appointment slots to allow for appropriate cleaning and decontamination of equipment and rooms. Staff wore appropriate personal protective equipment when managing these patients.

Waste was segregated and disposed of appropriately. Clinical and domestic waste bins were clearly labelled and emptied regularly. Sharps containers and hazardous waste bins were stored safely. During the assessment we observed staff cleaning beds and pillows between patients.

Staff followed a range of policies and standard operating procedures to support safe and consistent practice. Policies were also available to guide staff in the management of infection outbreaks and other related incidents.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were involved in planning, including when changes happen.

Medicines used within the diagnostic imaging service, including contrast media and injectable agents, were stored securely and checked regularly. Radiographers followed a 2 person check process when administering and documenting medicines. Batch numbers and expiry dates for contrast media were recorded to support traceability in the event of a product recall.

Emergency medicines and resuscitation equipment were available within imaging areas and were checked daily to ensure they were ready for use. Staff were trained to respond to medical emergencies and had access to medicines that could counteract the effects of certain drugs where required.

Radiology protocols were in place and reflected national guidance. Prescriptions for contrast media were authorised and signed by a radiologist and documented appropriately.

Staff demonstrated an understanding of contraindications and screened patients for allergies and relevant medical history prior to procedures to ensure it was safe to proceed.