Medserena Upright MRI 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

Our rating of well-led stayed the same. We rated well-led as requires improvement.

The provider's policies for complaints, incident reporting and medicines management were inconsistent and did not accurately reflect staff practice.

The service did not have effective monitoring processes relating to staff recruitment records and the reporting of scan results.

However,

Leaders promoted a positive work culture based on equality, diversity and inclusion. Staff felt respected, supported and valued. Leaders worked collaboratively with stakeholders and partners to plan and manage services.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider's vision was ‘we strive to be known as the provider of choice for upright open MRI services in the UK.'

The provider's aim was to provide a better MRI scan experience for people who could otherwise not tolerate an MRI scan procedure, such as those with claustrophobia.

The provider's spring meeting (2024) outlined the annual strategy for the service and included 3 strategic business objectives relating to increasing scan capacity and MRI experience, improving referrer confidence and to proactively engage with referring organisations.

Managers told us progress against the business objectives was reviewed as part of routine staff meetings. The staff we spoke with were aware of the provider's vision and strategy.

All the staff we spoke with were highly motivated and positive about their work. They told us there was a friendly, safety-focused and open culture and that they received good support from managers. They all told us there was a positive culture within the service and that staff worked well as a team.

The overall lead for the service was the operations director, who was also the nominated individual. The operations manager reported to the managing director and had responsibility for this location and another of the provider’s locations.

The operations manager was supported by the registered manager, who had additional responsibilities around infection prevention and control and quality monitoring audits. The operations manager and the registered manager were qualified radiographers who also undertook scans and were both primarily based at this location.

Staff spoke positively about the support they received from managers. They told us managers and senior leaders were visible, approachable and provided them with good support and guidance.

The provider’s whistle blower policy provided guidance for staff around raising any concerns. Staff could raise concerns internally to the managing director or to an external human resources service provider that was independent to the service.

Staff told us they felt confident they could raise any issues with their managers and that managers listened to them. Staff were aware of the whistleblowing policy and understood how to raise concerns if needed.

There had not been any whistle blower concerns of freedom to speak up concerns raised by the service or received by the Care Quality Commission during the past 12 months.

Staff told us the service had an inclusive working culture, and they were treated with respect and equity. Staff told us managers engaged with them regularly and they felt confident any concerns they raised would be listened to. The staff we spoke with told us they had not experienced any instances of unfair treatment, discrimination or harassment.

Staff received training in equality, diversity and human rights and had equality, diversity and inclusion policies in place to provide support and guidance. Managers told us equality, diversity and inclusion was embedded in the culture of the service.

The service had an equality, diversity and inclusion policy and this was also incorporated in the recruitment policies and processes. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers told us they routinely engaged with staff to maintain an inclusive, diverse, and supportive work environment. We looked at staff survey responses from 3 staff members from March 2025 and they all responded positively to survey questions relating to their role and the support they received from their managers and the wider organisation.

Staff engagement also took place through daily discussions and team meetings. Managers told us they also engaged with staff through annual staff events and social activities, such as meals out and Christmas and birthday celebrations.

All policies and procedures were reviewed and updated annually by the senior managers. The policies and procedures we looked at had been reviewed within the 12 months prior to our inspection and were scheduled for their next review during August 2025.

We found the provider's policies for complaints, incident reporting and medicines management were inconsistent and did not accurately reflect staff practice.

The incident form template in the provider's incident reporting policy only consisted of one page, whereas the incident reporting form templates held by and completed by staff at the service contained more detailed information and consisted of 2 pages. The operations manager confirmed this was an oversight and the policy required updating.

The provider's medicines management policy stated each site stocked 2 adrenaline auto-injectable pens but did not make any reference to other emergency medicines held on site such as aspirin tablets, smelling salts or emergency oxygen.

The provider's standard operating procedure for receiving and acting on complaints included contradictory information about complaint response timelines when compared to complaints information displayed in the waiting area. The complaints procedure also did not include any information about how people could escalate their concerns internally or externally, if they were not satisfied with the provider's initial response to their complaint.

Routine audit and monitoring of key processes (such as equipment safety and infection prevention and control) took place to monitor performance against safety standards and organisational objectives. However, we identified gaps in the monitoring processes relating to the reporting of scan results and staff recruitment records.

The service had a performance target to send scan image results or scan reports within 5 days (or within 10 days for specialist examinations). The operations manager told us they mostly achieved reporting targets and service users, partners and stakeholders also told us scan results were received in a timely manner. However, managers did not routinely collate actual performance data around reporting timelines for scan images and reports. This meant that any shortfalls in report delivery performance or any required improvements may not be easily identified.

We found electronic staff recruitment records were not effectively maintained during our inspection. The provider submitted evidence following the inspection to show appropriate recruitment checks had been completed in response to our inspection findings. Whilst individuals such as the operations manager were responsible for maintaining staff records, there had been no scheduled formal audit or monitoring undertaken on staff recruitment files to proactively check for completeness and compliance against the provider's recruitment policies.

We identified concerns around the fit and proper person's processes for company directors during our previous inspection. During this inspection we found improvements had been made. Recruitment records for the managing director showed appropriate checks had been undertaken, in line with regulatory requirements for fit and proper persons; directors.

Staff took part in daily huddles and staff meetings were held every 2 months. Meeting minutes showed key discussions took place around performance, risk, governance, audit findings and incidents. Actions were followed up at subsequent meetings. The managing director routinely attended staff meetings to provide corporate provider oversight.

Managers understood the key risks to the service and maintained an organisational risk register. The risk register showed that key risks were identified and control measures were put in place to mitigate risks.

Managers were aware of their responsibility to report notifiable incidents to external organisations. They told us there was a system to ensure safety alerts were actioned and cascaded to all staff.

People who used the service told us care and treatment was well co-ordinated, and staff engaged and kept them informed about their scan procedure and the reporting of scan results.

The provider had service level agreements in place with 2 NHS trusts from Greater Manchester. The service also accepted referrals from other NHS trusts and independent healthcare providers through occasional contracts or purchase order requests. The terms of individual agreements varied, with some services requiring full radiologist scan reports and other services only requesting scan images that their own clinicians would analyse and report on.

We spoke with stakeholder representatives from both NHS trusts that had service level agreements with the service. They told us they had positive working relationships with the managers and staff at the service.

The NHS trust stakeholders told us they had not yet undertaken formal engagement meetings, but they told us they worked collaboratively and had regular informal engagement with the service to support the planning and delivery of scans for people referred to the service. They told us they had no concerns about the service and managers kept them informed of any delays. They told us they were satisfied with the service’s performance around delivering timely scan results and reports.

Staff told us there was daily engagement with referring organisations and the consultant radiologists to plan and deliver scan services. Consultant radiologists told us they regularly engaged with staff and provided support and guidance when needed.

The service did not routinely engage with local communities due to the nature of the diagnostic scan services they provided, but there was routine public engagement through social media and marketing to promote the services offered.

Staff told us there was a culture of learning, innovation and improvement across the service. They told us learning from audits, incidents and people’s feedback was shared to aid learning and improvement. We saw evidence of shared learning and improvement during our inspection.

The service had made improvements in some areas identified as shortfalls at our previous inspection in August 2018, such as staff mandatory training processes and fit and proper persons processes for directors. However, further improvements were still required around governance processes.

The service was involved in research studies with external partners in relation to Ehlers-Danlos syndromes (EDS – a connective tissue disorder) and rheumatology conditions.

The service had implemented a novel process using artificial intelligence (AI) tools to improve MRI scan processes through shortened scan sequences, cloud-based AI processing and secure data handling.