Medserena Upright MRI 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

Our rating of safe improved. We rated safe as good.

The service had enough staff to care for people and keep them safe. Staff had training in key skills, understood how to protect people from abuse, and managed safety well. The service managed infection prevention and control risks well.

Staff assessed risks to people and acted on them. Premises and equipment were clean and well-maintained. The service had oversight of safety incidents and learned lessons from them.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses using paper-based accident and incident reporting forms, in line with the provider's incident reporting and management policy. Incidents were reviewed and investigated by staff with the appropriate level of seniority, such as the operations manager.

People who used the service told us they felt safe and did not have any concerns around safety incidents.

There had been no deaths, never events or serious incidents (of moderate or above harm) reported by the service during the 12 months prior to our inspection visit.

There had been 8 incidents reported by the service between March 2024 and July 2025. These related to people fainting, documentation errors and delayed scan reports. None of the incidents had resulted in any harm. The incident reports for these incidents showed each case had been appropriately investigated and improvement actions were identified to aid learning and minimise reoccurrence.

Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to people's care during daily safety huddles and routine staff meetings so shared learning could take place.

Staff were able to give examples of learning from incidents, such as the introduction of a floor cushion to reduce the risk of falls injuries to people during their scan procedure.

Staff understood the duty of candour. They were open and transparent and gave people who used the service and families a full explanation if and when things went wrong. There had been no incidents reported by the service that met the threshold for implementing the formal duty of candour during the 12 months prior to our inspection visit.

The service had operational policies that provided guidance for staff around the booking, admission and discharge of people who used the service.

People who used the service told us they were kept informed about their care and treatment at all stages, from their initial booking through to their scan procedure and reporting of their scan results.

The provider’s inclusion and exclusion criteria policy provided guidance for staff on who was eligible for admission to the service. The service mainly admitted people who were not able to undergo conventional MRI scans due to claustrophobia, if they were unable to lie down flat, or if they required a dynamic upright scan in a standing or extended position.

People with active implants or metal components in their body, those who weighed over 220kg or were too large to fit in the scanner, and those with mobility issues where they were unable to sit, stand or get themselves on to the scanner with minimal assistance were not eligible for admission to the service.

The service had policies for staff to follow if a person became unwell during their scan procedure. All the radiographers had completed adult resuscitation and basic life support training as a minimum.

Staff understood how to manage people’s risks during an emergency. They told us they carried out routine observations during the scan procedure and people whose health deteriorated would be promptly transferred to hospital by ambulance if they required emergency treatment. There had been no instances where a person required emergency transfer to hospital during the 12 months prior to our inspection visit.

Service partners spoke positively about the systems and pathways in place for people who used the service. They told us staff at the service fully understood and met their referral requirements and people’s scans and scan reports were completed in a timely manner.

The safeguarding policy provided guidance for staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as local authority safeguarding teams.

People who used the service told us they felt safe and were confident they could raise any safeguarding concerns they had with the staff.

Staff told us they had received safeguarding training and understood how to identify abuse and report safeguarding concerns. They told us learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings.

Staff completed training specific for their role on how to recognise and report abuse, in line with current intercollegiate guidance for adults and children. Records showed all administrative and radiographer staff had completed at least level 2 adult and children’s safeguarding training.

Training in the Mental Capacity Act, deprivation of liberty safeguards (DoLS), modern slavery and female genital mutilation training was incorporated into the adult and children’s safeguarding training. All staff had also completed Prevent (counter-terrorism strategy) training as part of their mandatory training.

The operations manager was the safeguarding lead for the service. The operations manager and the registered manager had both completed the higher level of children and adults safeguarding training (level 3).

There had been no safeguarding incidents reported by the service during the 12 months prior to our inspection.

The administrative staff carried out an initial telephone assessment for each person as part of the booking and referral triage process, to arrange a scan appointment and to discuss key risks and people’s needs and preferences. Any discrepancies in the referral or booking information or people identified with specific medical conditions, such as epilepsy, were escalated to the radiographers to assess their suitability for admission to the service.

On admission to the service, each person completed a questionnaire to identify any potential risks prior to their scan. This information was reviewed by the radiographer who discussed any risks with the person before determining if it was appropriate to undertake the MRI scan procedure.

People who used the service told us they underwent initial assessments and staff discussed and explained key risks to them prior to commencing scan procedures. They told us staff carried out regular observations and kept them informed during their scan procedure.

Information about people’s weight and height were requested as part of the initial assessment to enable the correct MRI scan parameters specific to each person. Where this information was not available, staff carried out weight and height measurements prior to commencing scan procedures.

Staff did not routinely carry out vital observations or assessments during scan procedures due to the short length of time taken to complete scans. However, the radiographers told us they continuously observed and communicated with people from the control room during their scan. Staff told us they would pause the scan if a person’s health deteriorated or the person required any intervention or support, such as if they felt anxiety or discomfort.

Staff could access an alarmed emergency stop button in the control room in case of an emergency. Staff could also break the glass between the control room if required. People undergoing scans were provided with a handheld emergency alarm device that immediately notified staff if the person had any concerns.

There were clear processes in place to escalate unexpected or significant findings identified during the MRI scans. Where any concerns or anomalies were identified, staff told us they kept the person undergoing the scan informed about the findings and additional steps required to keep them safe.

There had been one instance of unexpected scan findings during the 12 months prior to our inspection. Records showed the radiographer took appropriate actions including liaising with a consultant radiologist and facilitating prompt admission for the person to a local acute hospital.

The design, maintenance and use of facilities, premises and equipment kept people safe. The MRI suite and associated equipment complied with national safety guidelines, such as those from the Medicines and Healthcare products Regulatory Agency (MHRA).

All the areas we inspected were well maintained, free from clutter and suitable for providing safe care and treatment. There was sufficient space for storage of equipment and consumables. All areas were easily accessible, including for wheelchair access. Access to the premises was secure with coded entry and the MRI suite had lockable doors.

The service had suitable waiting areas and sufficient numbers of toilets for staff and service users, including disabled toilets. The MRI suite had two separate changing areas for people using the service. These were linked to the MRI control room and included secure lockers for people's valuables and emergency pull cords to notify staff during an emergency.

The type of MRI scanner used by the service enabled staff to turn it off without undertaking complex steps (such as quenching or helium purges). Staff followed clear instructions and maintained up to date log sheets to document switching off MRI equipment at the end of each day and restarting at the beginning of the next day.

The service had enough suitable equipment to help staff provide safe care and treatment. There was a planned maintenance schedule in place that listed when equipment was due for servicing.

Maintenance records showed the MRI scanning equipment underwent monthly maintenance and servicing by a dedicated engineer from the corporate provider. The cooling and air conditioning systems had also been serviced by an external contractor every 3 months.

Staff told us they received good support from the maintenance engineer. There had been 8 incidents relating to unexpected MRI equipment faults and records showed these had all been addressed promptly.

Radiographers carried out a daily calibration and quality check of the MRI scanning equipment using an imaging phantom at the beginning of each day. Records for June and July 2025 showed these daily checks had been completed and had passed, prior to undertaking scans.

The radiographers also carried out daily checks on emergency alarms and equipment such as weighing scales and a wheelchair. We found daily checklists were complete and up to date.

There was an automated external defibrillator device in the MRI control room for use during emergencies and this was checked daily by staff.

The service had suitable systems for managing fire safety, including fire risk assessments and routine testing of fire safety systems and equipment. Fire extinguishers were kept securely and within their service dates. Fire extinguishers were maintained by an external contractor at least annually. The service also had an MRI compatible fire extinguisher within the main scan room.

The service only had 1 small portable emergency oxygen cylinder on site. However, this was not stored securely, in line with Health and Safety Executive (HSE) guidelines for the storage of compressed gases. We raised this with the staff during our inspection. The service had an arrangement with an external oxygen cylinder manufacturer for the supply and replenishment of the oxygen cylinder.

The service had a business continuity plan, which provided guidance for staff to manage key risks that could affect the provision of care and treatment, such as auxiliary supply or power outages.

People who used the service told us they had not experienced any issues relating to equipment. They told us the equipment, premises and scan facilities were safe, well-maintained and provided a suitable environment for their care and treatment.

The service had policies outlining the processes for staff recruitment and training. Staff training and recruitment records were held electronically and maintained by the operations manager. During the inspection we found the electronic staff recruitment records were not complete and up to date. We found information such as references, right to work permits and inoculation histories were missing in the records we looked at. However, the operations manager was able to provide further evidence following the inspection to show all staff had appropriate recruitment checks undertaken when they commenced employment with the service.

We looked at records for the 4 radiographers and 3 administrative staff working for the service. Evidence provided following the inspection showed appropriate recruitment and pre-employment checks had been carried out for all of these staff.

The service had enough staff to keep people safe. The service had 4 radiographers. This included the operations manager and the registered manager, who were both substantively employed radiographers and routinely undertook scan procedures. They were supported by 2 additional bank radiographers, who had substantive employment elsewhere and provided support including during periods of sickness or leave absence.

The bank radiographers underwent the same level of induction, training and appraisal as the substantive staff. All 4 radiographers held up to date registrations with the Health and Care Professions Council (HCPC).

The radiographers were supported by 3 administrative staff who worked varying shift patterns. Staff sickness and turnover rates were low. The service did not routinely use agency staff. The service did not have any vacancies at the time of our inspection.

All scan procedures were scheduled in advance, enabling managers to plan and adjust staffing resources in advance according to people's needs. There was at least 1 radiographer and 2 administrative during weekdays and at least 1 radiographer and administrator on Saturdays during operating hours.

The radiographers worked with 11 consultant radiologists, who worked under practicing privileges. They were required to submit evidence of their qualifications, training, appraisals, General Medical Council (GMC) registration information and indemnity insurance information to the service on an annual basis. Practicing privileges were reviewed annually by the managing director and the operations manager. The records we looked at showed practicing privileges were up to date and all the consultant radiologist's records had been reviewed within the past 12 months prior to our inspection.

We identified concerns around the lack of mandatory training for administrative staff during our previous inspection in August 2018. During this inspection we found improvements had been made. The service had developed a comprehensive role-specific mandatory training programme for the radiographers and the administrative staff.

Staff received and kept up to date with their mandatory training annually. Overall training compliance of 97% had been achieved, indicating most staff had completed their mandatory training.

Staff told us they received annual appraisals. All eligible staff had completed their appraisals. Records showed all the radiographers and administrative staff had undergone induction training and competency-based assessments relevant to their role.

People who used the service told us there were enough staff at the service. They spoke positively about the way staff communicated and interacted with them and told us staff were professional, friendly and responsive to their needs. Staff told us there were enough staff, their workload was manageable and they received good support from their line managers.

All the areas we inspected were visibly clean and had suitable furnishings which were clean and well-maintained. There were enough hand washing sinks and hand sanitising gels. We observed staff following hand hygiene and 'bare below the elbow' guidance. Staff had access to personal protective equipment, such as gloves and aprons.

People who used the service told us the premises was visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment.

Staff followed the provider’s infection prevention and control (IPC) policy and completed mandatory IPC training. They understood the processes for managing risks associated with IPC.

Cleaning schedules defined the roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment. The radiographers were responsible for cleaning and decontaminating the equipment within the MRI suite. Domestic staff cleaned the general environment and equipment and had completed risk assessments related to entering and cleaning the MRI suite.

Staff were able to describe how they cleaned and decontaminated equipment, including deep cleaning if equipment became contaminated with bodily fluids. Staff had access to biohazard spillage kits and bodily fluid spillage kits. There were suitable arrangements for the safe handling, storage and disposal of clinical waste, including sharps.

People identified with a known infection were assessed as part of their initial assessment to determine if they were suitable for admission to the service.

The service had not reported any healthcare-acquired infections or outbreaks during the 12 months prior to our inspection.

The registered manager was the IPC lead for the service. Senior staff carried out monthly infection control environmental audits and hand hygiene audits to check compliance against infection prevention and control policies and guidelines. Audit results between October 2024 and July 2025 showed high levels of staff compliance with infection control and hand hygiene standards.

Managers told us if any shortfalls in hand hygiene or infection control compliance were identified, then these would be discussed with individual staff members to improve compliance and this would also be followed up at subsequent audits.

The service did not prescribe or administer any medicines, including controlled drugs, for routine scan procedures. The service did not undertake any MRI scans that required the use of contrast media (a substance used to enhance scan images).

The service only kept emergency medicines such as adrenaline (auto-injectable pen), aspirin 75mg tablets (for heart emergencies) and smelling salts (to revive someone after fainting) as well as a portable emergency oxygen cylinder (to support breathing in emergencies).

Emergency medicines were ordered using an authorised prescription from a consultant radiologist and staff understood how to safely store, handle and discard emergency medicines.

We found emergency medicines were stored appropriately in the control room and were kept within their expiry dates. Radiographers carried out daily stock and expiry date checks and we saw checklists for June and July 2025 were complete and up to date.