Whipps Cross University 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 abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to premises and equipment and safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 service managed patient safety incidents well and lessons were learnt to continually improve practice. When staff reported incidents, staff told us that they were usually involved in investigations and asked for their input. Staff told us they received feedback from incidents they reported, and learning was shared in team meetings, huddles and by email. Staff told us they did not feel blamed and were not treated negatively when things went wrong. Staff told us they were supported by their managers and colleagues and were treated with understanding. They felt lessons were learned from safety incidents and changes were made to reduce risks. Staff were able to provide examples of recent incidents and share what was learnt or changes to practice made as a result. Most generally understood their responsibilities around duty of candour and when this should be applied.

There was a culture of prioritising patient safety and learning across the department. Staff were encouraged to report incidents and leaders told us there was a good incident reporting culture across the service. However, staff also said reporting incidents about repeat imaging in MRI due to equipment failure of pulse oximetry monitors was not always commonplace. Incident data we reviewed from the 12 months prior to the inspection showed only one incident had been recorded in this period. Although the investigation of this noted that the failure of this equipment was getting worse and causing unnecessary delays in patient care.

There was evidence that changes had been made because of incidents reported. Managers developed training for example, in response to previous incidents a Pause and Check simulation session was conducted in July 2025 designed to test radiographers’ attention to detail, reinforce best practice and improve compliance with safety checks to reduce future errors. Most staff told us the teaching environment was positive and supportive, and they were encouraged to participate in training opportunities. Although, some staff commented that there was not always time available to complete training due to staffing pressures and workload.

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 service worked with people and healthcare partners to establish and maintain safe systems of care. There were processes in place to ensure registered healthcare professionals who request imaging procedures as part of their routine or advanced clinical practice had the appropriate training and entitlement to make referrals in accordance with the Non-Medical Staff Imaging Referrals Policy. Staff told us that radiographers vetted referrals to justify imaging was necessary. There was a hot seat radiologist who could be contacted with queries and support was provided by modality leads when questions arose.

Pause and Check posters were in all imaging areas we visited. They were designed to act as a reminder of the checks that needed to be made when any diagnostic imaging examinations were being performed.

The service had clear local rules and employer’s procedures in place to restrict radiation exposure to staff and people and to promote the safe use of ionising radiation. Where local rules were due for review, these reviews had taken place and were awaiting approval. The service ensured that the radiation protection advisor (RPA) and the medical physics expert (MPE) were easily accessible for providing radiation safety advice. The service had radiation protection supervisors (RPS) in the departments which used ionising radiation.

The service had a process in place for managing significant findings to ensure prompt communication of urgent and/or critical findings. Staff understood the processes for escalating unexpected or significant findings at examination and reporting. However, the service had identified that the process was not robust as there was potential for the significant finding to be sent to the wrong clinician, and it relied upon referrers to be regularly checking their email, confirming a read receipt and picking up the escalations. We saw this recorded on the service risk register. A control measure was identified to email more than one person to reduce risk that the requestor was on leave and result was not communicated. However, we were not assured that this was sufficient to ensure the consistent and timely communication of significant findings which are necessary to avoid missed diagnoses and delays to patient treatment.

We observed that patients were provided with information about how they would receive the results of their imaging.

The service did not always provide staff with the necessary training and support to protect people from avoidable harm, neglect, and abuse.

People using the service told us they felt safe and supported. Staff received safeguarding training at the correct level for their roles on how to recognise and report abuse. Staff were trained to level 2 in both adult and children safeguarding. Data provided following our inspection showed that safeguarding mandatory training compliance amongst most staff was good. Compliance with safeguarding adults and children level 2 in ultrasound was below target at 76.4% and 66.7% respectively. Staff told us radiographers involved in investigations of non-accidental injury in children should be trained to a level 3 in safeguarding children, however we did not see this reflected in the Skeletal Survey for Suspected Physical Abuse in Children protocol. Compliance with safeguarding level 3 training was below target amongst ultrasound (50%) and core service staff (47.6%). The trust informed us that in some cases delays in staff profiles being updated with completed training and staff being incorrectly assigned modules were contributing to poor compliance.

Staff knew what constituted a safeguarding concern and knew their responsibilities to follow safeguarding policies and procedures. We reviewed the hospital’s safeguarding policies for adults and children and found it was comprehensive. Although the Safeguarding Policy for Children was due for review in February 2024, we were informed this was still being reviewed and was going through the trust’s internal approval process. Staff told us they knew how to access safeguarding policies and advice if needed. Although we saw that the trust’s safeguarding policies covered all locations, some staff who rotated between Whipps Cross Hospital and other hospitals within the trust told us they would struggle to report safeguarding concerns at Whipps Cross as they were unfamiliar with reporting guidelines for the site.

The service had a lone working policy, to promote safe working practices and to heighten staff awareness regarding safety issues when working alone. Although this policy was under review, we saw that lone working was also covered in the trust security policy. Staff told us that if a dental X-ray was required after hours a radiographer from A&E would need to take the patient to the dental X-ray unit in another part of the hospital alone. We were informed that if they felt unsafe, they could ask a member of security to accompany them.

The service ensured children and young people who did not attend appointments were contacted. We saw there was a process in place to ensure missed appointments were followed up to safeguard children and young people.

The service did not work well with people to understand and manage risks. Staff did not provide 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 people who used the service. Staff identified and responded appropriately to changing risks to people. Patients we spoke to were aware of the use and risk of radiation. We saw information posters in some waiting areas explaining the risk and benefit of the use of radiation. We observed staff followed the Society of Radiographers “pause and check” guidance when checking patient’s identity and verifying critical information before proceeding with radiographic examinations and administering injections. However, incident data we reviewed showed lapses in this step were identified as contributing to several incidents. Although pause and check audit data generally showed high compliance in most areas of the protocol, January 2025 audit data showed checks to confirm the patient’s identity were performed only 52% of the time in GP X-ray and 68% of the time in Outpatient X-ray. Compliance had improved in Outpatient X-ray in June 2025 to 100% but reduced to 44% in A&E X-ray.

Staff in MRI completed timeout forms to confirm patient identity and conduct thorough MRI safety screening for patients and any accompanying persons. Audit data showed staff did not always comply with this. Data from July 2025 showed 53% of patients did not have a timeout form completed. We saw that training was being reinforced to address the poor audit results.

Training in basic life support was provided as part of mandatory training, however compliance amongst core service staff was lower than target at 74.1%. Staff in ultrasound told us that emergency call bells did not work and had not worked for several years. Emergency call bells are necessary to alert staff to the need for urgent assistance. However, staff understood procedures for managing a patient’s deterioration. A plan to address the faulty call bell system was included on the site imaging estates action plan. Staff in MRI were clear on the process for safely evacuating a patient. Staff told us there had been a mock cardiac arrest to ensure staff were aware of their role and to assess the effectiveness of the process.

We observed there was not always posters advising patients to notify the team if they suspected they might be pregnant in all appropriate areas. Where signage was available, this was not always translated or did not have an image to raise an accessible awareness of the effects of ionising radiation amongst individuals capable of childbearing. The service carried out safety checks including checks to assess a person’s pregnancy status. This is necessary to minimising the risks like developmental delays and birth defects to a foetus. However, audit data we reviewed for checking last menstrual period (LMP) showed that 34% of LMP forms were not found on the system and 20% had their LMP form inaccurately filled in. We received varied responses from staff about whether confirming pregnancy status for patients was inclusive. This meant procedures did not always comply with inclusive pregnancy status guidelines for ionising radiation.

Staff made efforts to ensure services were delivered and made accessible to take account of the needs of different people. Admin staff told us schedulers ask patient whether they need transport or interpreters for appointments.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and estates supported the delivery of safe care and protected people.

The service mostly had suitable signage to warn people where ionising radiation was being used. However, there was no signage at the entrance to the MRI unit to warn people about the strong magnetic field and associated risks. This could pose a safety risk, particularly for people unfamiliar with the environment. We raised this during our inspection; however, we did not see that this was included in the imaging estates action plan for the estates team to address this.

We observed that the waiting area for CT outpatients was not fit for purpose, there were a few seats around a pillar in the centre of an area overseeing and overhearing the interventional radiology department. We also observed that some changing rooms were not wheelchair accessible, which meant people attending in a wheelchair changed in the disabled toilets. The A&E radiology service did not have an area for patients to change and there was only one toilet available for staff and patients. The layout of A&E radiology also meant that there was poor visibility of ambulatory waiting patients. We saw that the unsuitable environment in A&E radiology was identified on the service risk register as a high risk, control measures had been identified to mitigate the risks this was posing.

Only the A&E CT scanner had a camera to allow for patient monitoring and visualisation by the operator during scans. During our inspection we observed that the microphones of the CT scanners were not on, this meant patients would not have been seen or heard by the operator if they needed to communicate with staff.

We observed that chemicals and substances used for cleaning purposes such as chlorine tablets that are hazardous to health were observed in areas that were not locked and therefore could be accessible to patients and visitors to the area.

Staff in ultrasound informed us that a leak in the roof had resulted in an ultrasound room not being able to be used. We saw that a plan had been put in place for the site estates team to address this.

There were quality assurance processes in place to ensure that imaging equipment was tested and maintained appropriately for use. We saw that some equipment was overdue quality assurance testing, however arrangements had been made to test them in August 2025. There was an appropriate and up to date standard operating procedure for managing equipment in the event of a fault.

We saw that some equipment was not always tested and serviced in a timely fashion with some equipment we looked at displaying stickers that indicated a service was due as far back as February 2023. Resuscitation equipment was readily available for both adults and children, and staff checked them regularly. We saw that equipment such as resus trolleys, wheelchairs and fire extinguishers were labelled to indicate whether they were MR safe.

The service completed radiation risk assessments for all uses of radiation, which took account of occupational safety. All assessments we reviewed were in date of review. However, we saw that some target dates for actions identified in risk assessments had passed without the actions being addressed. The service monitored staff for radiation exposure. We saw evidence of dose reports produced detailing analysis of staff doses including where doses were higher than expected. We were informed that an increase in staff being allocated office space in the back area of the nuclear medicine department was posing a radiation protection risk due to increased footfall by these staff in the main nuclear medicine corridor. The main nuclear medicine corridor was a designated Supervised Area. Access to radiation areas should be restricted as far as reasonably practicable, due to the nature of the work, risk of spread of contamination in the event of a spill and the security required for radioactive material in line with Ionising Radiations Regulations (2017). Although this issue was initially raised in February 2025, the risk assessment was completed during our inspection and was added to the service risk register following the inspection. Control measures were identified and put in place which allowed the risk to be reduced to ‘low’.

Staff working with ionising radiation wore radiation dose monitoring badges which were monitored by the service to identify over exposure risks. Staff and carers used personal protective equipment when needed. Lead aprons and lead screens were routinely checked for their integrity.

There was a PACS team which looked after all IT equipment and oversaw quality assurance of monitors including home workstations. Engineering support was supplied by formal maintenance contracts and by the clinical engineering team, which meant in house staff could perform some maintenance of the scanners and respond promptly in the event of equipment failure.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels and skill mix were planned and reviewed so that people always received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix during our inspection was lower than the planned levels and staffing was reallocated to provide cover for staff absence. Staffing levels were escalated at morning bed meetings and the site team was kept informed on staffing issues.

Sickness rates in the service were high. In the 12 months prior to the inspection, sickness rates were 5.3% across all staff groups, which exceeded the trust target of less than 4%. Staff felt there were not enough radiologists and radiographers to meet the demands of the service yet felt they were generally managing with current staffing levels. Staff told us they felt it was challenging to manage the often-heavy workload in the A&E CT scanner after 5pm with just two radiographers. They told us an additional radiographer would also ensure there was sufficient staff for manual handling. Staff in ultrasound told us there was short staffing amongst sonographers due to a high staff turnover and there was not a paediatric sonographer in post. Staff competency data showed only 36% of sonographers were competent in paediatric imaging. Data we reviewed showed that the fill rate for band 7 sonographers in the 6 months prior to our inspection varied from 74% - 85%.

The use of agency staff had significantly reduced. There was use of bank staffing, generally from within the hospital’s workforce. Successful uplift and recruitment of imaging assistants had also aided a reduction in the use of bank staffing and provided necessary support for teams. However, the service risk register stated a lack of a substantively appointed Band 5 admin lead in the department was posing a risk of compromised supervision, coordination, and operational flow of administrative functions within radiology.

The current staffing model for radiographers did pose a risk to the sustainability of the service overnight and at weekends. At the time of the inspection radiographers were employed on Monday to Friday, 9 to 5 contracts with the remaining work being covered by a voluntary local agreement. However, leaders told us of transformation work being done to address the staffing model and introduce a 7-day service.

Leaders told us sustainability of staffing was a risk in the breast clinic. We saw that a risk to breast imaging services and staff development due to staff shortages was recorded as a high risk on the service risk register. During our inspection, staff told us staffing was low due to staff being on leave. Staff leave was not always coordinated to maintain service provision, and this negatively impacted the ability to consistently provide one stop clinics for patients. It was recorded on the service risk register that a lack of established radiologist staffing was available to meet clinical demands and support breast radiologist attendance at multidisciplinary meetings (MDM). As clinical activity was prioritised this meant there was not always a radiologist presence at MDMs for discussion of cases, this increased the risk of missed or incorrect diagnosis.

Many staff in the integrated cardiology unit rotate between Whipps Cross Hospital and other hospitals within the trust. Some staff told us they found it difficult working across hospital sites, as the training they received was not specific to procedures at Whipps Cross Hospital. They told us staff should be paired for shifts when it is their first time at Whipps Cross for support. This did not always happen, and the lack of knowledge and familiarity with the service and environment could be stressful for new staff. Following the inspection, the trust confirmed that all staff received an induction and that they intended to strengthen shadowing and coaching with a mentor for new starters.

A shortage of established radiologist staffing was contributing to the continued outsourcing of radiology reporting. Outsourcing reporting was aiding the reduction of the reporting backlog. However, this arrangement was considered by staff to be less efficient than uplifting the substantive radiologist staffing as the service level agreement in place meant there was a 7-day turnaround for reports. Staff told us this was longer than a substantive radiologist would typically take.

Staff received training appropriate to their role and were supported with structured induction and preceptorship programmes. However, overall compliance in mandatory training in admin and clerical staff, and staff in ultrasound was below target.

Not all staff were receiving regular review of their work (appraisal) which also gave them the chance to discuss opportunities for progression, learning and development. Data we reviewed showed that compliance was 80% in June 2025. This was below the trust target of 90% minimum. This ranged in staff groups from 75% for radiology nursing staff to 90% of ultrasound staff.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found that CT scanner rooms were generally cluttered and messy. Velcro straps were dirty in both scanners and that the tabletops under mattresses were also dirty. We observed that although some mobile X-ray units displayed, I am clean stickers, they were not visibly clean.

Although there were processes in place to regularly clean the environment and equipment. many cleaning schedules we reviewed were not routinely completed and did not demonstrate that all areas were cleaned regularly. We observed there were ‘I am clean’ stickers on equipment which were dated to identify them as clean. However, some we reviewed had dates form several days prior.

There was not always signage across the service to promote good hand hygiene, and we found that some hand sanitiser dispensers were empty. Many staff were also wearing footwear that did not comply with the trust uniform policy. However, we saw that hand hygiene practice was appropriate, and staff were bare below their elbows.

There were sharps bins available for the safe disposal of sharps. We observed that staff separated waste appropriately but did not always dispose of clinical waste safely. We saw some overflowing sharps bins and sharps bins with temporary closure mechanisms left open when the bins were left unattended. We informed staff of this during our inspection and saw that overflowing sharps bins were removed immediately. We observed several closed uncollected sharps bins in the A&E CT scanner. Staff told us this was due to delays in collecting and replenishing sharps bins since the hospital’s trial of using an environmentally sustainable sharps bin option.

Staff identified people with infections which allowed staff to offer appropriate appointments. Staff told us they would see people with infections at the end of the day to reduce risk of spreading infections. In the event of a patient attending with an infectious disease, staff had access to onsite cleaning staff and materials. We saw staff had access to personal protective equipment (PPE) should they require it, and they had enough time to perform cleaning between appointments.

Most of the patients we spoke to described the service as clean, welcoming and professional, and said they felt safe using it.

There were systems in place to ensure that medicines were prescribed and administered appropriately, including contrast media (an injected substance used to enhance the visibility of internal structures). However, we did not see the temperature of warmer cabinets was displayed and routinely monitored to ensure contrast was stored at an appropriate temperature to maintain effectiveness and help prevent extravasation.

We observed staff carried out safety checks before all scans including those involving contrast medium. Staff completed documentation to ensure they recorded details such as the patients’ medical history, which cannula was used and consent. Audit data indicated that safety checks were not always completed appropriately, data from April 2025 showed that of 150 CT contrast forms analysed, only 2 were filled out correctly. However, many of the incorrectly completed forms were related to staff not individually signing the checklist at the end of the form.

The service had patient group directions (PGD) in place for radiographers and sonographers. PGDs provide a legal framework that allows some registered health professionals to administer medicines within their scope of practice so that the patient does not have to see a prescriber.

Staff we spoke with gave conflicting information about the process for managing reactions to contrast. Some staff told us they could give antihistamines under a PGD and had training to give intramuscular adrenaline, although commented that they did not feel confident to do so. Other discussions contradicted this, and some staff told us they could not provide antihistamines or adrenaline and would seek help from radiologists or the medical emergency team.