Chenies Mews 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. Control of Substances Hazardous to Health (COSHH) were managed in line with regulations and medicines were kept locked during the assessment, which was in line with safety regulations.

Staffing levels were appropriate for the service’s activity. Radiologists worked under practising privileges and were drawn from the local NHS trust.

The service had protocols for emergency response situations. Safety equipment was well managed, with daily checks of the resuscitation trolley. Staff maintained competencies through annual review processes, although some competency records for existing staff required updating. All radiographers were trained in MRI modalities. While emergency equipment checks were in place, the service did not have clear records to demonstrate routine testing of emergency call cords.

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 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.

The service was able to describe several mechanisms used to support local learning. Staff told us incidents and key messages were reviewed regularly and some learning was displayed on the magnetic resonance imaging noticeboard. A monthly administrative quality audit was undertaken, and the service also referred to a magnetic resonance safety audit completed by medical physics support from the local NHS trust. The service had also undertaken a simulation exercise, which showed that learning activity was taking place, although follow-up arrangements for staff not present required strengthening.

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 maintained a risk register, reviewed biannually, and used an electronic system to track operational and organisational risks.

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 to ensure safe use of MRI.

The service used structured documentation to support safe pathways and transitions for higher-risk or specialist imaging activity. For example, the pacemaker magnetic resonance imaging procedure checklist required confirmation of device compatibility, cardiology review, safety form completion, pre-scan examination room checks and post-scan communication. The service also used a Buscopan pre-procedure checklist to screen for contraindications and a patient-specific directive form for cardiac imaging that included patient identification, allergy status, renal function checks, emergency equipment availability and administration records. These processes supported consistent screening, escalation and decision-making before imaging took place.

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. 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. The service had also completed relevant environmental monitoring and used a structured system to record and review risks. Governance meetings included discussion of audit findings and safety processes.

The service had systems in place to safeguard adults and children 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.

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 provided with written information about contrast agents and 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 scan room, subject to safety screening.

Staff confirmed that risks were discussed with patients prior to procedures involving contrast media. Written information was provided, and patients were advised on what to do in the event of a delayed reaction. 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 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 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.

Although risk assessments were in place, we identified that the magnetic resonance imaging phantom risk assessment, while in date, was not fully completed at the time of the assessment. Sections relating to actions, mitigations and review were incomplete, which reduced assurance that all identified risks had been fully considered and documented.

Site-specific safety procedures and operational guidelines that governed the use of NHS 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.

Emergency preparedness arrangements were well established. 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. The premises and core facilities were the responsibility of the landlord under a service level agreement. 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. However, assurance was limited at the time of the assessment regarding testing and maintenance arrangements for the fire curtain. Staff were not able to clearly demonstrate when it had last been checked, and supporting service level agreement documentation with external partners was not readily available during the assessment.

Access controls and key safety signage were in place, with entry to the magnetic resonance imaging lobby restricted via code access.

The service maintained a current risk register and had completed relevant risk assessments, including for health and safety, COSHH.

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 cardiology specialists, with a cardiology fellow present for clinical sessions involving contrast administration and other injections. The service had arrangements in place to check if doctors had completed mandatory training, safeguarding training, and Disclosure and Barring Service (DBS) checks. This meant they had assurance of compliance with statutory requirements.

Competency frameworks were in place for employed staff, and there was evidence of site-specific competencies in areas such as contrast administration, cannulation, anaphylaxis management and equipment handling. However, the service told us its competency matrix was under review and due to be updated. Records for some existing staff had not been fully updated or recently reviewed at the time of the assessment, which reduced assurance that competency oversight was consistently current across the whole team.

There were sufficient staffing levels that met demand, with managers able to provide cover for sickness or leave. There was evidence of staff engagement and development, with routine meetings taking place, and action plans tracked from those discussions. Staff training compliance among 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 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 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.

Medicines and contrast media were stored securely and appropriately managed, with temperature-monitored conditions in place for gadolinium‑based contrast agents. 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. 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.