The New Victoria 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. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

This is the first assessment for this service as a stand alone assessment service group. 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 department managed patient safety incidents well and lessons were learnt to continually improve practice. Staff understood how to report safety incidents and said there was a no blame culture, and they were encouraged to report incidents. When staff reported incidents, they were involved in investigations and received feedback from incidents they reported. Incident learning was shared in team meetings, huddles and displayed on staff information boards. The imaging department also shared learnings with other departments via a quarterly Realm bulletin, the bulletins included case summaries and learning points. Staff said this was received positively by other departments. We observed Realm bulletins displayed in staff areas throughout the hospital. Learning was also disseminated to other acute care hospitals across London, as well as shared throughout the Bupa network.

There was a culture of prioritising patient safety and learning across the department. Management said they encouraged staff involved in incidents to create learning slides to share with the team as an opportunity for development and reflection. We saw examples of shared learning slides that were developed after incident reviews.

In the 12 months before to the assessment, 112 incidents were reported for the department. The 3 most common incident categories accounted for 46% of all incidents and related to appointments, admissions, transfers and discharges; records, documents, test results and scans; and investigations, images and laboratory tests. A specimen handling error was identified as a near miss. The issue was identified and corrected, and no harm occurred. An after-action review was held promptly and identified a potential trend. A learning response was then initiated, led by the theatre team. This led to additional teaching being delivered across the hospital and learning being shared across Bupa networks.

Management reviewed incidents and made changes to improve relevant processes. For example, communication between teams had been strengthened and a weekly summary booking email had been introduced following incidents of double booking image intensifier equipment. Workshops had been held with the Patient Services Advisors (PSA) team to identify opportunities to improve processes after errors occurred during periods of increased workload.

The monthly Integrated Governance Committee had oversight of incident themes and trends. The committee monitored actions arising from incidents and ensured learning was shared across the service. Incidents involving children and young people were reviewed separately from overall incident data, to ensure enhanced oversight and scrutiny.

The hospital’s policies and procedures emphasised the importance of duty of candour and supported staff to apply it consistently. The hospital had an in-date Duty of Candour Policy which reflected national guidance. Other policies, including the Accidental or Unintended Medical Exposure to Ionising Radiation policy and the Management of Radiological Reporting Discrepancies policy, reinforced the application of duty of candour and supported staff to get it right. Staff understood their duty of candour responsibilities and when to use them. One of the imaging department’s stated objectives was to ensure staff were honest and open with patients, including explaining what had happened and offering an apology when mistakes were made. In the 12 months prior to the inspection, the imaging department had applied the duty of candour on two occasions.

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.

The department worked with patients and healthcare partners to establish and maintain safe systems of care. Most referrals to the imaging department were received internally, with referrals from external providers received via secure email. Patient records we reviewed had completed referral forms. Radiographers reviewed all referrals to ensure that patients’ needs could be safely met. Where necessary, staff contacted referrers to clarify clinical details or request additional information. The departments referral criteria was in date and reviewed annually. Patients were informed in advance about preparation requirements, including fasting instructions and what to wear for MRI appointments.

‘Pause and Check’ posters were displayed in all imaging areas we visited. These acted as prompts to remind staff of the required safety checks before imaging was performed.

Clear local rules were in place to restrict radiation exposure to staff and patients and to promote the safe use of ionising radiation. However, we found some out‑of‑date versions of local rules stored on mobile equipment. We alerted staff to this, and the current local rules were put on the mobile equipment, however old versions were not removed, which could create uncertainty for staff about which guidance to follow.

A Radiation protection advisor (RPA) and Medical Physics Expert (MPE) were accessible for providing radiation safety advice and completed required annual audits. The department had an identified radiation protection supervisor (RPS) in line with the Ionising Radiations Regulations 2017 (IRR17).

Transitions between services were well managed. When adverse reactions occurred, or urgent care was required, staff escalated this promptly. This meant patients received immediate support and treatment, maintaining their safety. We saw examples of this in incident reporting. The hospital was implementing Bupa connected care pathways for specialities including breast care, gynaecology and cardiology. As this was a new initiative, the impact assessment had not been completed at the time of the inspection.

There were processes in place for managing significant findings to ensure urgent and critical results were communicated to the referrer promptly. The Imaging Secretary was responsible for releasing urgent reports to the referrer, however out of hours, when no Imaging Secretary was available, Radiologists could release their reports directly to the referrer. Staff demonstrated an understanding of the escalation processes for unexpected or significant findings identified during examinations or reporting.

Staff reported good working relationships with local providers and described engagement activities, including hosting information evenings for GPs and community services. This supported effective communication between services and helped ensure patients experienced coordinated and joined‑up care.

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.

Patients were protected from the risk of abuse and avoidable harm. Staff knew how to identify and respond to safeguarding concerns. Systems and oversight arrangements ensured that concerns were reported, investigated and shared appropriately. Safeguarding incidents were reviewed at the monthly Integrated Governance Committee. Patients using the service told us they felt safe and supported.

Safeguarding training compliance was 92% across required levels. All staff required to complete Safeguarding Adults Level 2 and Safeguarding Children Levels 1 and 2 training were up to date with their training. Twelve of the 13 staff required to complete Safeguarding Adults Level 1 had completed the training. Training compliance was monitored through governance reports. We saw that management had followed up with the one staff member not up to date with their Safeguarding Adults Level 1 to ensure they complete it.

The hospital had a safeguarding adults policy and a safeguarding children policy, both of which were up to date and reflected national guidance. Staff were able to explain what constituted a safeguarding concern and were familiar with internal reporting procedures and external escalation routes. Staff gave examples of safeguarding alerts they had raised. Staff told us that they felt well supported by the safeguarding leads and that advice was easily available. In the 12 months prior to the inspection no safeguarding incidents were reported in the imaging department.

The chaperone policy was up to date. We saw information displayed in imaging rooms and waiting areas informing patients that they could request a chaperone. Imaging assistants acted as chaperones when required; however, there was no formal training in place to support staff in this role.

All imaging assistants were female. Staff told us that if a male chaperone was requested, they would arrange for a male PSA or a radiographer to act as the chaperone, although they said this situation had not occurred. The chaperone policy stated that a formal chaperone would usually be of the same gender as the patient and that all non-clinical staff members who acted as formal chaperones must have had sufficient training to understand the role expected of them. None of the patients we spoke with raised concerns about the availability of chaperones.

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.

Staff carried out risk assessments for patients who used the service and safety questionnaires were completed before all imaging. Staff used these assessments to identify and respond appropriately to risks to patients. Staff communicated clearly to help patients understand their care and treatment and involved them in managing risks related to their procedures. Staff followed the Society of Radiographers “pause and check” guidance when checking patient’s identity and verifying critical information before proceeding with imaging, this was reflected in patient records reviewed.

Patients told us they felt informed, supported and safe throughout their visit. Patients were aware of the use of radiation and associated risks. Posters were displayed in waiting areas explaining the risk and benefits of the use of radiation. Posters advising patients to inform staff if they thought they might be pregnant were displayed in waiting rooms and imaging suites. The Examinations on Persons of Childbearing Potential policy was in date and reviewed annually. The policy emphasised the importance of patients being fully informed about why the service needed to establish pregnancy status prior to certain imaging examinations.

Staff made efforts to ensure services were delivered and made accessible to take account of the needs of different patients. Patients said they could bring a family member or carer to appointments if they wanted, we saw staff accommodating the needs of patients attending to support patients in waiting areas and in appointments. PSA staff identified accessibility and translation needs during the booking of appointments and arranged adjustments where required.

The service provided care to children and young people. A paediatric imaging policy was up to date and reviewed on a 3 yearly basis. Information was displayed in staff areas about procedures for scanning children and young people and there was a list of paediatric radiologists. A paediatric nurse was scheduled for all interventional procedures carried out on a child under 16 years. We saw positive feedback from parents regarding how staff supported children undergoing imaging.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients were cared for in clean, well-maintained and appropriately equipped surroundings. Patient waiting areas, changing rooms and toilets were tidy, accessible and clearly signposted.

There were several initiatives underway to improve the physical environment in the department. The mammography room was undergoing renovations to increase its size and upgrade the equipment. New ultrasound machines had recently been purchased and were in use. Staff told us they had made efforts to improve the appearance of the waiting room after patient feedback that the environment was drab. The X‑ray equipment was ageing and no longer fully supported for repairs by the manufacturer, creating a risk of ongoing unreliability. The risk register stated that a mobile X‑ray machine could be used as a temporary mitigation if the general X‑ray room was unavailable. The mobile X‑ray equipment was covered by a best‑endeavours maintenance contract, meaning that replacement parts were no longer readily available and repairs could not be guaranteed in the event of a breakdown. A business case for the capital replacement of the X‑ray equipment had been approved, with replacement planned for 2026; however, a confirmed implementation date was not available.

Environmental safety was managed through systems and oversight. The service had fire safety arrangements, including staff receiving fire safety training and those we spoke with were familiar with evacuation routes and assembly points. There was clear signage for patients and visitors to support safe transitions between areas in the event of an emergency. A fire risk assessment was completed in September 2025. The local fire brigade was aware of the specific requirements if there was a fire in or in the vicinity of the MRI area.

Radiation safety was well managed and embedded across imaging modalities. Controlled areas were clearly identified with appropriate radiation warning signage, and access was restricted in line with the Ionising Radiation Regulations (2017). Staff wore personal dose monitoring badges, and audits of dose reference levels were completed monthly. Audits showed that staff radiation exposure was consistently low and within safe limits, providing assurance that radiation risks were being effectively managed. Radiation risk assessments were reviewed regularly, and findings were reported through governance meetings. Mandatory radiation safety training completion was 100% for technician and support roles. However, compliance among allied health professionals was 82%, which was below the hospital’s target of 90%. Departmental governance meeting minutes showed that the radiation safety for staff training had been added in March 2026, and managers had contacted all staff who had not completed the training to ensure they completed the training.

There were systems in place to make sure imaging equipment was checked, tested and maintained for safe use. Equipment audits were completed and outcomes shared with staff. The hospital used an external provider for servicing and quality checks, with oversight provided through the hospitals quarterly Medical Devices Safety Group. The Planned Preventive Maintenance schedule showed compliance with audit requirements.

There was no designated changing room within the MRI suite. There were changing facilities in the ultrasound area; however, this was located some distance from the MRI area and meant patients would need to walk through a waiting area wearing a hospital gown, which could compromise their dignity. As a result, some patients changed their clothing in the magnet room. Staff explained that, to reduce the need for this, patients were informed at the time of booking about appropriate clothing to wear for their scan so that changing would not be required. They also said only patients who were fully mobile used the magnet room for changing so this could be done quickly. Managers were aware of the issue and said they had no concerns about unnecessary exposure to magnetic fields.

The service had a lone working policy, to promote safe working practices and to heighten staff awareness regarding safety issues when working alone. However, there were times when lone working practices in MRI did not follow the lone working policy or the local rules. On Saturdays, MRI operated from 4:00 to 6:00pm, staffed by 1 radiographer, after the rest of the imaging department closed. On Sundays, the MRI suite operated from 8:00am to 2:00 PM, staffed by 1 radiographer, when the imaging department was closed. The MRI local rules stated that scanning should not take place unless there were at least two members of staff within the imaging department. Although the local rules allowed lone working by an MRI‑authorised person for on‑call, out‑of‑hours scans, this did not reflect routine practice observed at the time of inspection.

We scored the service as 3. The evidence showed a good standard. 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.

There were enough qualified, skilled and experienced staff to provide safe care that met patient’s needs. Staffing levels and skill mix was reviewed at daily operational meetings, where any shortfalls were identified and additional clinical staff were arranged as needed to meet service requirements. Nursing and clinical staffing levels were reviewed annually as part of the annual budget review cycle, and whenever there is a material change in service delivery, acuity, or dependency. Leaders said the purpose of this review is to ensure that staffing levels, skill mix and deployment of nursing and clinical staff are safe, effective and sufficient to meet the needs of patients. Bank staff were deployed where necessary to maintain safe staffing levels. From April 2025 to March 2026 the average use of bank staff was 7%, there was no agency staff used. Staff said they had regular bank staff who were familiar with the department and their practices. This was corroborated by low turnover data of bank staff averaging 2% from April 2025 to March 2026.

Management said they were using additional bank staff to support the introduction of a new IT system. This was to release staff who were involved in designing the system so they could support colleagues during its implementation.

The imaging team included radiographers, modality leads, imaging assistants and PSAs. From April 2025 to March 2026 the average vacancy rate for the department was 8%. The average sickness absence rate was 4%. This was in line with the hospitals vacancy and sickness levels. Staff turnover was low with an average turnover of contracted staff of 1% in the 12 months prior to the inspection. Staff retention was described as good and staff did not raise concerns regarding staffing levels.

Specialist consultants worked at the hospital under practising privileges and were not directly employed by the hospital. The hospital had effective systems to grant, review and monitor practising privileges to make sure consultants were appropriately qualified and competent. The Practising Privileges Corporate Governance Committee had oversight of doctors working under practising privileges.

Appropriate recruitment checks were completed before staff began work. The recruitment policy was up to date. New starters completed a structured induction programme tailored to their role, covering organisational structure, policies, freedom to speak up and emergency procedures. Staff received regular supervision and an annual appraisal. Appraisal data for the imaging department showed a 97% completion rate. Appraisal data for consultants with practicing privileges was 96%.

Mandatory training compliance ranged from 82% to 100%, for most core modules in the imaging department, However, compliance for Adult Basic Life Support was only 62%. Departmental governance minutes showed that management had followed up with staff who did not have 100% compliance to ensure they completed mandatory training. Mandatory training was monitored at the fortnightly imaging Quality, Compliance & Risk Meeting and the hospital wide IGC. The minutes of the Integrated Governance Committee meeting held in March 2026 reported overall mandatory training compliance of 91% across the organisation. It was noted that the hospital’s new human resources system did not yet enable mandatory training compliance to be reviewed at departmental level. We were not provided with a timeframe for when this functionality would be available.

We scored the service as 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.

Clinical areas were generally visibly clean, organised and well maintained. Hand sanitizer was available throughout the department, including waiting areas. Facilities for hand washing were available. We saw some mobile equipment was dusty, however this was quickly remedied when we pointed this out to staff. Patients said they thought the hospital was clean, tidy and accessible to them.

Staff followed infection prevention and control (IPC) procedures, including effective hand hygiene, appropriate use of personal protective equipment (PPE), and the safe management of sharps and clinical waste. Staff received training in IPC and the hospital Infection Control Policy and Manual was up to date. The provider completed IPC audits, including hand hygiene and aseptic technique audits on a bi‑annual basis, and a standard precautions audit annually. The department performed well in local IPC audits. The most recent audit results demonstrated compliance levels of over 97% in standard precautions, hand hygiene and aseptic technique. Audit findings were reviewed through governance meetings to support ongoing monitoring and service improvement.

Staff said patients with suspected or confirmed communicable or infectious diseases were usually booked at the end of the day to reduce the risk of cross‑infection and to allow sufficient time for enhanced cleaning of equipment following imaging. If a patient attended with an infectious disease, staff had access to onsite cleaning staff, appropriate cleaning materials and PPE. The Imaging Patients with Suspected or Known Communicable Diseases procedure was in date and readily available to staff to support practice.

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.

There were systems in place to ensure medicines, including contrast media, were prescribed and administered safely and appropriately. The hospital’s medicines management policy was in date and included arrangements for the transport, storage, administration and disposal of medicines. Records reviewed showed medicine administration charts were completed accurately and were up to date.

Medicines were stored securely in controlled areas. Drug cupboards were locked, and access was restricted to authorised staff. Drug expiry date checks were completed monthly and demonstrated all medicines were in date. Ambient temperature checks were carried out daily and recorded. In the MRI Suite, the contrast was stored in the magnet room which had a regulated temperature. There was a process for alarms to alert staff if the temperature went outside the 18 to 25° set range.

The service had patient group directions (PGD) in place for radiographers administering contrast agents. PGDs provide a legal framework that allows specific registered health professionals to administer medicines within their scope of practice so that the patient did not have to see a prescriber. The PDGs set out the qualifications and training required for staff to administer medicines using PGDs to ensure they had to skills to do so safely. There was a register of staff who routinely administer medicines, demonstrating that they had been appropriately trained and signed off under the relevant PGD.

In the 12 months prior to the inspection 3 medication incidents were reported in the imaging department. Staff were encouraged to report medicine errors or near misses. Incidents were investigated and learnings implemented where required. Incidents were reviewed through governance meetings, and learning was used to strengthen practice and improve safety. For example, we reviewed a shared learning slide that outlined actions following an unintended exposure incident. These included improvements to the X-ray pause and check process, as well as increased awareness of specific features of the X-ray machine that was not previously known.