Spire Harrogate Clinic

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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.

Clinical areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks for patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant people 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.

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 had systems and processes in place to support a positive learning culture and encourage learning from incidents, complaints and patient feedback. There had been no serious incidents or deaths reported within the diagnostic service during the previous 12 months.

The service was able to access and participate in wider Spire Healthcare multidisciplinary team mortality meetings. This enabled learning, themes and outcomes identified across the organisation to be shared and considered locally to support service improvement.

The service reported 34 diagnostic imaging-related patient safety incidents between 1 August 2025 and 31 July 2026. Incidents related to radiology (20), diagnosis (9), documentation/patient information (4) and equipment (1). All incidents had been reviewed by the service and were classified as causing no physical harm to patients. Leaders were able to demonstrate how incidents were analysed to identify trends, themes and opportunities for learning.

Information relating to incident reporting, complaints management and duty of candour was clearly displayed and accessible to both staff and patients. Staff demonstrated a good understanding of reporting processes and told us they knew how to escalate concerns appropriately. Staff understood their responsibilities under the duty of candour and described the importance of being open and transparent with people when something had gone wrong.

The service had specific guidance available to support staff in responding to radiation-related incidents. Guidance for Significant Accidental or Unintended Exposures (SAUE) was displayed within the diagnostic department and provided clear instructions regarding reporting arrangements, escalation pathways and immediate actions required following an incident.

Learning from incidents and complaints was routinely shared with staff through several mechanisms, including one-to-one discussions, governance meetings, team briefings and organisational newsletters. Staff told us they received regular feedback on incidents and were kept informed about actions taken and lessons learned.

Daily multidisciplinary safety huddles provided a structured forum for staff to review incidents, complaints, ongoing investigations and emerging risks. These discussions supported shared learning and helped ensure improvements were embedded into practice. The service also produced a weekly rapid response summary, which collated information from incidents, complaints, patient feedback and audit activity discussed at the daily safety huddles. This summary was reviewed during weekly team discussions and displayed on staff noticeboards to ensure learning was shared widely across the service.

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.

Spire Harrogate Clinic provided private diagnostic services for patients referred by their consultants for diagnostic investigations. The service had clear referral and acceptance processes in place to support safe and appropriate patient care. Referral forms were audited through the Clinic 16 audit programme, which demonstrated 100% compliance. Referral information captured key patient details and potential risks, including mobility needs, communication requirements and relevant clinical history. Staff told us they reviewed referrals to ensure patient identification details, contact information, clinical history, requested examinations and referrer details were complete before appointments were arranged.

The service had systems in place to ensure patients were appropriately assessed before diagnostic procedures were undertaken. Patients attending for MRI scans completed safety questionnaires designed to identify potential risks, including the presence of pacemakers, implanted defibrillators and other medical devices. Women of childbearing age were asked about the possibility of pregnancy. Theclinic had an up-to-date pregnancy policy and relevant patient information was displayed within the department. During the assessment, we saw completed safety questionnaires demonstrating these checks were consistently undertaken.

We tracked 3 patients through their diagnostic pathway from admission to discharge and observed systems and processes that supported the safe delivery of care. Patients were correctly identified, appropriately assessed and received the diagnostic procedure requested. Diagnostic procedures were undertaken by suitably qualified and competent staff. Additional support and escalation to off-site radiologist expertise was available when required.

The service had implemented the Society of Radiographers’ ‘Pause and Check’ process to reduce the risk of wrong patient, wrong site and wrong procedure incidents. This process required staff to confirm the correct patient, the correct area to be imaged and the correct imaging modality before commencing examinations. Audit results for the previous 6 months demonstrated 100% compliance with this process.

Patient records were maintained using a combination of paper and electronic systems. Staff told us paper records were scanned onto electronic systems to support access to patient information. Diagnostic images were stored and shared through the Picture Archiving and Communication System (PACS), which supported the secure storage, review and transfer of radiological images. Record keeping and radiology documentation were monitored through Clinic 02 and Clinic 33a audits. While the Clinic 33a single patient record audit did not initially achieve the required compliance target, action plans were developed and implemented. Evidence provided by leaders demonstrated that all identified actions had been completed.

There were systems to support continuity of care following diagnostic investigations. Once reviewed and reported by a radiologist, diagnostic results, including X-rays and MRI scans, were shared with patients and relevant healthcare professionals, including GPs. Staff told us results were routinely communicated within 4 days of the investigation being completed, supporting timely clinical decision-making and onward care.

Young people aged 13 years and over could access the diagnostic service. The service had age-appropriate radiology protocols and standard operating procedures in place to support safe care for children and young people attending the clinic. Staff had completed training in the care and safeguarding of children, young people and adolescents, ensuring they understood their responsibilities when caring for younger patients.

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.

The service had clear safeguarding arrangements in place to protect people from abuse, neglect, discrimination and avoidable harm. The Clinical Services Manager had overall responsibility for safeguarding within the clinic and provided oversight to ensure safeguarding policies were implemented and safeguarding concerns were appropriately managed and reported to relevant safeguarding authorities when required.

Safeguarding policies, procedures and guidance were readily available for staff to access. Information regarding chaperones and their role was displayed throughout the clinic, and patients were able to request a chaperone during consultations, examinations and procedures.

Staff demonstrated a good understanding of safeguarding responsibilities and were able to describe how to identify adults and children who may be at risk of, or experiencing, abuse or harm. They understood local reporting procedures and the importance of working in partnership with other organisations and safeguarding agencies to protect people. Staff were also aware of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

Staff described the processes they followed to safeguard children attending the service and told us they adhered to established procedures for children and young people visiting the clinic. The service reported there had been no safeguarding incidents during 2025/26. As a result, safeguarding supervision had not been required during this period.

Training records demonstrated high levels of compliance with safeguarding training requirements. Safeguarding training attendance for adults and children at levels 1, 3 and 4 was 100%. Allied Health Professional and nursing staff predominantly completed safeguarding training at levels 2 and 3. Training records confirmed that safeguarding adults level 2 and children's level 2 training was not required for those staff groups in accordance with organisational training requirements.

The service had robust recruitment and employment checks in place to help ensure patients were protected from unsuitable individuals. Disclosure and Barring Service (DBS) records showed all 10-radiology staff, including bank staff, had current enhanced DBS checks.

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 had arrangements in place to identify, monitor and respond to risks to people using the diagnostic service. Staff had access to guidance relating to the management of deteriorating patients, resuscitation and sepsis. Staff told us they knew how to access this guidance and described the actions they would take if a patient became unwell.

We observed the daily multidisciplinary safety huddle, where staff discussed operational and clinical risks. Discussions included identifying the named resuscitation lead for the day and allocating specific responsibilities to staff should a patient deteriorate. This helped ensure staff were clear about their roles and responsibilities in responding to emergencies.

The service had systems in place to ensure clinically significant diagnostic findings were escalated promptly. Staff told us that where a radiologist identified an urgent or unexpected finding following an X-ray or MRI scan, they would immediately notify the clinic who would then notify the referrer. Findings would then be acknowledged and communicated to the referring clinician to support timely follow-up and treatment.

The service had one centrally located resuscitation trolley that was used throughout the clinic. Staff explained that, should a patient deteriorate within the diagnostic department, a member of staff would retrieve the resuscitation trolley from the day-case area. During the assessment, staff confirmed a formal risk assessment had not previously been completed to consider the potential risk of multiple patients deteriorating simultaneously in different areas of the clinic. Following the assessment, leaders provided a risk assessment that recognised and evaluated this risk.

We also observed that paediatric and adult resuscitation equipment was stored together within the same trolley and emergency equipment bags. This was raised with senior clinic leaders during the assessment to ensure they considered whether the current arrangements supported prompt access to the correct equipment during an emergency.

The diagnostic department maintained a resuscitation grab bag containing a small oxygen cylinder, adult and paediatric airways and Ambu bags. Records demonstrated that equipment checks were completed monthly and recorded electronically on SharePoint, with additional weekly checks of the external emergency bag to ensure equipment remained available and fit for use. Staff accessed emergency medicines from the central resuscitation trolley.

The clinic did not have an on-site medical presence. Staff told us that should a patient deteriorate and require emergency treatment or transfer, they would contact emergency services via 999 and arrange transfer to the local NHS trust. Although the service did not have a formal service level agreement with the local NHS trust, senior leaders had met with trust representatives in January 2025 to confirm escalation arrangements and emergency response processes.

The service had achieved Resuscitation Quality Improvement (RQI) Excellence accreditation. This programme supported staff competence in cardiopulmonary resuscitation and immediate life support for both adults and children. Staff described recent emergency scenario training exercises, which had identified opportunities for further improvement and learning.

Staff supported people to understand and participate in decisions about their care and treatment. Patients were provided with information about diagnostic procedures, associated risks and safety requirements. Staff adapted communication methods to meet individual needs, including supporting people with communication difficulties. Advocacy services were available where required.

The service actively sought feedback from patients through surveys and other mechanisms. Patient feedback regarding diagnostic services was consistently positive and demonstrated that people felt informed, supported and involved throughout their care.

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 diagnostic department at Spire Harrogate Clinic was located on the ground floor, supporting accessibility for people using the service. The environment was suitable for a range of patient needs, with wheelchairs and a step available for patients who required assistance. Patients attending the department had access to private changing facilities, and seating was available in the main corridor while waiting for appointments.

The diagnostic department was well maintained and designed to promote patient safety. Appropriate access controls were in place to restrict entry to authorised areas, and safety signage was displayed throughout the department. Patients attending for magnetic resonance imaging (MRI) scans could alert staff to their arrival using a doorbell located in the main corridor. The MRI and X-ray rooms were situated adjacent to each other, and each diagnostic room had a dedicated control area accessible only to staff.

The service had sufficient equipment to support the safe delivery of diagnostic services. Equipment was visibly clean, maintained in good condition and met relevant safety requirements. Staff completed daily safety checks of diagnostic equipment, and maintenance records demonstrated that equipment was serviced and maintained in accordance with manufacturer recommendations and organisational requirements. Training records confirmed staff were competent to operate diagnostic equipment and understood the management of different waste streams.

The radiology equipment had recently undergone comprehensive quality assurance testing. Results demonstrated compliance with required safety and performance standards, with no significant concerns identified. This provided assurance that imaging equipment was operating effectively and supporting the delivery of safe, high-quality diagnostic services.

Access to clinical areas was appropriately controlled. Patients and visitors could only enter secure patient areas when authorised by staff. Local rules for MRI, X-ray and C-arm equipment were available and accessible within the relevant clinical areas. C-arm local rules were attached directly to the equipment, and MRI local rules confirmed that an environmental risk assessment had been completed for the MRI suite.

The service monitored the quality and accuracy of diagnostic processes through audit activity. The image discrepancy and post-examination documentation audit demonstrated 100% compliance over the previous 6 months, indicating documentation processes were consistently completed in line with local requirements.

Environmental risks were subject to ongoing monitoring. A Legionella Risk Assessment and Water Hygiene Survey completed on 15 May 2025 identified several actions. Most actions had either been completed or were planned for completion within agreed timescales. One outstanding action remained subject to ongoing discussions with the building landlord.

Health and safety arrangements were well established. The most recent quarterly health and safety audits demonstrated 100% compliance. The clinic also conducted quarterly checks of emergency spill kits, including hazardous waste, biohazard, chemical, urine, vomit and formalin spill kits. Records demonstrated that essential supplies, such as gloves, masks, absorbent materials and waste disposal bags, were available and regularly replenished.

We scored the service as 3. The service made sure there were adequate numbers of qualified, skilled and experienced staff. Staff received effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The service used a structured daily safe staffing tool to determine staffing requirements based on anticipated activity levels. Within diagnostics, the imaging establishment tool used activity data extracted directly from the Radiology Information System (RIS). The system assigned staffing requirements according to the type and complexity of diagnostic activity, taking account of the average time required to undertake specific investigations. Theatre activity data was also incorporated into workforce planning. Daily staffing reviews considered the expected activity across diagnostic modalities and allocated staff accordingly.

Three-monthly staffing data identified periods where staffing levels had fallen below planned requirements within the diagnostic service. However, data for July 2026 demonstrated that actual radiographer staffing hours met the required staffing levels. Although shortfalls in healthcare assistant hours continued during this period, leaders had implemented measures to mitigate associated risks. The Imaging Manager provided clinical support when required and managed activity to avoid overlaps in diagnostic examinations, such as MRI, fluoroscopy and X-ray appointments. This helped ensure suitably qualified staff were available to undertake procedures safely and maintain patient safety.

The service had access to appropriate medical support. Radiologist cover was available throughout clinic opening hours. The permanent diagnostic workforce consisted of an Imaging Manager, two radiographers and one healthcare assistant. The imaging team routinely worked between 8am and 8pm from Monday to Friday to support delivery of the MRI service. Staffing arrangements remained flexible to accommodate changes in demand, including late referrals, and bank staff were used when required to maintain service provision during periods of leave or absence.

At the time of assessment, diagnostics and outpatient services had two vacancies consisting of a part-time registered nurse post and a bank nurse post. During the previous 12 months, eight staff had left the organisation, with turnover evenly split between clinical and non-clinical staff groups. Sickness absence averaged 1.6%, which was significantly below the wider Spire Healthcare group average of 5%.

The service had comprehensive recruitment, induction and competency processes. New staff completed a structured induction programme, including an induction workbook, competency assessments, role-specific training, hospital induction and safety questionnaires. Staff told us induction programmes were tailored to individual roles and learning needs. Opportunities for ongoing development were available, including apprenticeship programmes supported through Spire Healthcare.

Radiologists worked under practising privileges arrangements. Robust processes were in place to verify qualifications, competence and suitability before privileges were granted. Applications were reviewed through the Practising Privileges Advisory Group, and required checks were completed before approval. We reviewed evidence demonstrating that newly appointed radiologists had completed this process. Other radiologists had transferred from another local Spire hospital and had undergone the required verification procedures. The clinic worked with 25 radiologists, including 5 interventional radiologists. Leaders maintained oversight through a monitoring system which confirmed professional registrations, appraisals, indemnity insurance and other credentialing requirements remained current for 2025/26. Training records reviewed demonstrated consultant radiologists had completed competency assessments relating to specialist diagnostic equipment.

Mandatory training arrangements supported staff to undertake their roles safely and effectively. Training included legal and regulatory requirements, safeguarding, infection prevention and control, information governance, equality and diversity, fire safety, health and safety, medical devices, point of care testing, antimicrobial resistance, quality improvement and leadership subjects.

Training compliance was monitored weekly. Records showed Allied Health Professionals and diagnostic staff had achieved nearly 100% compliance with mandatory training requirements. However, completion rates for Immediate Life Support (ILS) were below target, and leaders recognised improvements were required. One Allied Health Professional had completed paediatric immediate life support training.

Additional training completed by staff included sepsis management, deteriorating patient recognition, mental health awareness, learning disability, autism, dementia, consent, mental capacity and Deprivation of Liberty Safeguards. Compliance rates across these subjects were high, with most courses achieving 100% completion.

Staff also completed role-specific training relevant to diagnostic services, including MRI Safety and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) training. The service supported learning through simulation exercises and reflective practice. In 2026 staff completed a failure of x-ray termination simulation, which resulted in a review of Significant Accidental or Unintended Exposure (SAUE) terminology and local practice.

We scored the service a 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 had clear leadership and governance arrangements in place to support effective infection prevention and control (IPC). At organisational level, the Chief Executive Officer retained overall responsibility for ensuring effective IPC arrangements across Spire Healthcare. At Spire Harrogate Clinic, the Clinical Lead was responsible for implementing IPC policies and monitoring compliance. Staff had access to advice and support from local and corporate microbiologists, the Director of Infection Prevention and Control (DIPC), IPC link colleagues and Occupational Health services. Organisational flowcharts demonstrated a well-established IPC network across the Spire Healthcare group to support local services.

The clinic had developed a local Infection Prevention and Control Strategy focused on four key pillars: Providing a clean and appropriate environment, monitoring and reporting infections, antimicrobial stewardship and compliance and culture.

During our assessment, the diagnostic department was visibly clean and well maintained. Clinical areas contained appropriate furnishings and equipment, which were clean and in good condition. Cleaning records were complete and demonstrated that routine cleaning was undertaken in line with local requirements.

We tracked 2 patients through their diagnostic pathway and observed staff following IPC procedures. Rooms and equipment were cleaned between patient use, staff completed hand hygiene appropriately, and personal protective equipment (PPE) was readily available and used when required. Training records confirmed radiography staff had completed aseptic non-touch technique (ANTT) training to support safe clinical practice.

Staff demonstrated a good understanding of IPC principles. Hand hygiene and bare below the elbows guidance were displayed throughout clinical areas, and staff had access to IPC policies and procedures through the clinic intranet.

The service monitored compliance through a programme of IPC audits. Hand hygiene, environmental cleanliness and cleaning audits completed in 2026 all demonstrated 100% compliance.

The service had appropriate arrangements for the decontamination of reusable medical devices. Policies clearly outlined responsibilities for the decontamination and management of reusable surgical instruments and aligned with national guidance and Health Technical Memorandum (HTM) 01-01. Guidance included requirements relating to PPE, environmental cleanliness, equipment maintenance, staff competence and training. These arrangements supported the safe decontamination of equipment and helped minimise the risk of healthcare-associated infections.

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.

The service had arrangements in place to support the safe management of medicines and staff followed processes relating to the storage, handling, administration, recording and disposal of medicines in line with national guidance and local procedures. Leaders told us the Spire Healthcare Medicines Management Policy was under review to ensure it remained aligned with current best practice and organisational requirements.

Staff had access to up-to-date medicines information and clinical guidance through the EOLAS Medical digital knowledge management system. The application was available to staff and consultants, with QR codes displayed throughout the clinic and access available via the Spire Healthcare intranet. Staff told us the Spire Healthcare Adult Antimicrobial Guide was available through the EOLAS platform, enabling timely access to prescribing and medicines-related information when required.

The service participated in antimicrobial stewardship (AMS) arrangements across the wider Spire Healthcare Yorkshire network. The Clinical Services Manager attended quarterly antimicrobial stewardship meetings hosted through Spire Leeds. Information relating to microbiology surveillance, including surgical site infection swab tracking, was reviewed to identify trends and themes. Any concerns identified through this process were escalated through medical governance and practising privileges forums as appropriate.

We checked a sample of medicines stored within the diagnostic department and found all medicines were within their expiry dates and stored securely. Access to medicines cupboards was controlled. Keys were held in a designated location outside the diagnostic department and staff were required to sign keys in and out, providing an audit trail of access.

The service monitored environmental temperatures in medicines storage areas to ensure medicines were stored within recommended temperature ranges. Temperature monitoring was undertaken electronically and transferred to a central monitoring system, allowing leaders to identify and respond promptly to any temperature excursions that could affect medicine quality or effectiveness.

The clinic did not have a permanently based pharmacy service. However, pharmacy support was provided through a pharmacist from another Spire Healthcare hospital who visited the clinic quarterly.  Staff told us the pharmacist could also be contacted between visits if advice or support was required. Weekly stock checks were completed by clinic staff to ensure adequate medicines supplies were maintained, and medicines stock levels were reviewed during the pharmacist's monthly visits.

Governance arrangements were in place to support safe medicines management. However, there were no medicines audits specifically allocated to the imaging department. While medicines storage and stock management arrangements were monitored, the absence of department-specific medicines audits limited assurance regarding ongoing compliance with medicines management processes within the diagnostic service.