Chenies Mews 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.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service operated with a clear mission, focused on delivering a high-quality imaging 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. Although the registered manager, who also served as the chief executive officer, was not always present on site, they were 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. This was supported by a range of assurance processes seen during the assessment. The service described a board structure that met every two months and maintained a local risk register. It also undertook regular assurance activity, including monthly administrative quality audit, magnetic resonance safety review, hand hygiene audit, and scheduled accessibility review. Staff told us issues identified through audit were discussed through governance routes and administrative staff meetings, which supported follow-up and local oversight.

The service maintained oversight of mandatory training compliance and staff safety checks. It also had a formal mechanism to verify and record Disclosure and Barring Service status for staff.

The service maintained a risk register that identified accountable leads and mitigating actions for each listed risk.

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. While systems were in place to flag performance concerns, some staff were not able to describe key performance indicators or reporting thresholds, as oversight was primarily held at management level.

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.

Although patient feedback was routinely collected and reviewed, the service was unable to provide clear examples of how feedback had directly informed service changes at the time of the assessment.

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.

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.

The service also demonstrated innovation through its imaging research activity. Staff told us more than 20 research projects had been completed over the previous eight years, with a substantial number ongoing at the time of the assessment. These included work in liver imaging, cardiac imaging, cardiac amyloid and studies using perfusion mapping to improve understanding of the ageing heart. This showed the service contributed to service development and the wider advancement of specialist imaging practice.