Queens 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 people were protected from abuse and avoidable harm, had a proactive and positive culture of safety, established and maintained safe systems of care, worked with people to understand and manage risks, assessed and managed the risk of infection and maintained safe and effective staffing levels. This was the first inspection for this assessment service group. This key question has been rated good. This meant people were safe and protected from avoidable harm.

The service had a good learning culture and people could raise concerns. Staff reported incidents and managers investigated thoroughly. People were protected and kept safe. Staff understood and managed risk. Staff assessed and managed the risk of infection and had a proactive and positive culture of safety.

Staff worked well together and mostly felt supported by their leaders, however this was not consistent throughout all areas with some staff and unsafe staffing levels.

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 a proactive and positive culture of safety, based on openness and honesty. Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had effective systems in place for managing patient safety incidents, and staff were familiar with how to use these systems. Staff demonstrated an understanding of the trust’s electronic incident reporting system and were mostly confident in using the system. However, some staff told us that they felt the system was difficult to use and that it took a long time to report an incident. Staff knew what incidents they were required to report.

Incident data was routinely reviewed and clearly showed patterns in harm levels, incident types, and areas requiring attention, which supported ongoing learning and continuous improvement.

The expected process was that incidents were reviewed initially by the service manager or responsible person, followed by a secondary review by the radiation compliance team. Due to capacity this was not always possible. To ensure that this process continued to function effectively, the radiation compliance team used the data to identify low‑ or no‑harm incidents and closed these directly, allowing the process to remain timely and consistent.

This meant that managers could focus on incidents involving actual or potential patient harm, ensuring that the service responded promptly, implemented learning, and took targeted action where it mattered most.

We reviewed incidents which had been reported between November 2024 and November 2025. One incident had resulted in severe harm with 2 being reported as moderate harm. There had been 1 near miss serious incidents in the previous 12 months. We saw staff and managers documented immediate actions, undertook appropriate investigations, and created new processes and action plans where required.

Staff told us that learning from incidents was shared through a range of formal and informal methods, including individual feedback, noticeboards, newsletters and email communication.

Staff understood duty of candour and the importance of being open, honest and transparent with patients when things went wrong. The incident data that we reviewed showed that duty of candour was completed when appropriate.

Staff told us that regular continuous professional development sessions were available and communicated through email.

The service worked with patients 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 patients moved between different services.

Diagnostic imaging services were available to both inpatients and outpatients. Internal referrals were received from the emergency department, outpatient clinics, and inpatient wards, while external referrals were accepted from GP practices and other community services. Most external referrals were received electronically, enabling clinicians to provide all relevant clinical information, including any additional needs or adjustments required. All referrals were vetted and triaged by a clinician to ensure they were appropriate and that appointments were scheduled within suitable timescales.

The trust monitored did‑not‑attend (DNA) rates across all diagnostic services. Where concerns were identified about patients who had missed appointments, this information was shared with the referring clinician so that appropriate follow‑up could take place.

There was a clear process to guide staff when significant or unexpected findings were identified. This process was based on the Royal College of Radiologists’ 2016 guidance for alerting critical, urgent, and significant unexpected findings. The guidance clearly outlined what clinicians, administrative staff, and managers needed to do to ensure timely communication with patients and appropriate escalation. Staff told us that they were aware of this process and that it was followed when required.

The service used a picture archiving and communication system (PACS), which allowed staff across the trust to access imaging securely and supported continuity of care.

Staff followed ‘pause and check’ guidance when confirming a patient’s identity and verifying information before proceeding with examinations. This was in line with the Society of Radiographers guidance to make sure the correct patient was scanned. Throughout the department we saw posters reminding staff of this process and audits completed in all areas of the imaging department showed that staff were 100% compliant with identity checks. Formal training around ‘pause and check’ was included in the induction for new staff.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting patients’ right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Whilst staff received safeguarding training in line with trust policy these requirements were not in line with the intercollegiate document (2025) safeguarding children and young people and children and young people in care: Competencies for health care staff which states that non clinical staff who have contact with adults and children should be trained to level 2. This was raised with the trust who confirmed that this was due to be reviewed and that there was a plan in place to increase training for non clinical staff to level 2. Clinical staff were expected to achieve level 3 safeguarding competency with non-clinical staff to achieve level 1. Mandatory training records showed that over 97% of clinical staff had achieved this except for medical staff where only 33% of staff had achieved this. 100% of non-clinical staff within the department had achieved level 1.

The service had clear safeguarding policies for both adults and children, which were accessible to all staff. Staff told us they understood how to raise safeguarding concerns and felt confident to do so. They also reported that they could seek advice from the trust’s safeguarding team when additional support or guidance was needed.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Staff completed risk assessments for all patients using the service to ensure that imaging was completed as safely as possible. We observed staff discussing the risks of radiation with patients and ensuring that they were fully informed prior to any investigations taking place.

Staff carried out safety checks before all scans, including those involving contrast medium, and documented key information such as the patient’s medical history, the cannula used and confirmation of consent. Monthly audits showed 100% compliance with contrast safety check documentation throughout 2025.

Staff recognised and knew how to respond appropriately to new or emerging risks. Staff carried out safety checks to find out if patients were pregnant prior to scans. This was necessary to minimise the risks to the foetus, and we saw information posters which advised of the risks of radiation during pregnancy. Staff audited patient records to ensure safety checks were completed before CT scans were performed. Data showed that between January and December 2025 staff were 100% compliant.

Staff completed additional checks within the MRI department. This was because of additional risks associated with the MRI scans for example where people had metal on or inside their body. We observed staff completing these further checks prior to patients entering the MRI suite. We also saw posters throughout the department reminding both staff and patients of the dangers associate with this. Audits of the safety checks which were completed in MRI were carried out and data reviewed showed that between January and December 2025 the service was 100% compliant.

When patients were referred for CT scans, staff assessed whether it was appropriate for them to be booked onto the portable CT scanning unit, and patients with mobility issues were not allocated to the unit.

At the time of our inspection there was no policy or guidance in place which explained what staff should do in the event that a patient’s condition deteriorated whilst in the department. The trust advised that this was covered by existing policies and guidelines. These included the resuscitation policy and the adult inpatient observations and escalation guideline. However, following an incident which occurred at one of the trust’s community sites a trust wide review of guidance was completed. The review showed the guidance focused on inpatients and ward staff. It was therefore not directly applicable to diagnostic imaging departments. As a result, a trust wide draft guidance document has been developed, although this had not been approved or released to staff at the time of inspection.

Inpatients frequently attended the department for imaging. Staff in diagnostic imaging did not routinely complete clinical observations such as the National Early Warning Score (NEWS), which is used to assess how unwell a patient may be. Ward staff escorted patients that required this.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff kept corridors and communal areas clear of clutter. Storerooms were organised and chemicals were stored in line with Control of Substances Hazardous to Health regulations (COSHH).

The department had clear signage about radiation used. Warning notices were positioned at entrances, preparation and equipment spaces. This alerted patients and staff to be extra vigilant and protected them from excess radiation.

There were resuscitation trolleys available throughout the department. Staff carried out regular checks to ensure they were appropriately stocked and ready for use. Trolleys were secured using safety tags in line with trust policy.

In the department there were paediatric emergency bags mounted on the walls which contained equipment intended for both adults and children. However, this was not clearly indicated on the bags or surrounding signage. Staff told us there had been occasions where adult equipment was required but staff were unaware that it was stored within these bags. We raised this with leaders who have addressed this to ensure that the risk of delay is removed.

Staff carried out routine safety checks of imaging equipment. They ensured that machines were functioning correctly and met required standards. Annual servicing was completed within the expected timeframes. Records demonstrated that equipment maintenance was up to date. Staff had access to an up-to-date procedure for managing equipment in the event of a fault.

Annual radiation protection advisor surveys were completed across all areas. 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.

An image optimisation team was in place, alongside a dedicated X‑ray quality assurance team trained to carry out routine equipment checks and calibration to ensure machines remained safe and effective.

Managers had a structured process to identify equipment approaching the end of its lifecycle. Scheduled replacement planning began up to two years before the expected expiration date. Staff started risk assessments and monitoring of equipment as part of an ongoing review process. Equipment was categorised as low, moderate, or high risk depending on its condition and performance. As items moved into the financial year in which replacement was due, their risk rating was escalated to extreme if no confirmed replacement plan was in place. Extreme cases were referred to the new and emerging risk group for further oversight and action.

Across the trust, 24 pieces of imaging equipment were identified as being within the equipment replacement phase. Of these, 14 were already at or beyond their recommended replacement point. Leaders were aware of this and ensured that all affected equipment underwent appropriate testing and monitoring to confirm it remained safe and effective for continued use.

The department used a portable CT scanning unit which was located outside the department. The environment within the portable unit was clean, tidy, and well maintained.

Staff and patients had clear procedures to follow in case of fire. Fire safety wardens conducted regular checks of fire extinguishers and fire exits. Fire exits in all areas were clearly marked and easily accessible.

Staff had access to evacuation procedures should an emergency occur whilst a patient was in the MRI scanner. Staff received training in this.

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.

Staff within most areas felt that there were enough staff to meet the demands of the patients, however this was not consistent across all departments. Some staff reported that their areas were heavily staffed with students and newly qualified staff who required high levels of support. We were told that usually these staff would have longer time slots of 30 minutes to see patients however due to capacity they were working to the standard 20 minutes time slots that experienced staff were. Staff told us that due to the high volumes of newly qualified staff working independently this increased pressure on experience staff as they were having to provide support alongside their own workload.

Bank staff were used when needed and leaders reallocated staff to cover any absence or shortfall. Staff occasionally worked at other sites within the trust to support teams. Regular bank staff had full access to systems to ensure care was not disrupted.

As part of the inspection process we requested staffing data, as of January 2026 the service had 92.4% of whole time equivalent (WTE) staff, with a vacancy rate of 7.6% WTE staff. This was slightly above the NHS national average for vacancies.

91% of staff were compliant with the trust’s mandatory training requirements which exceeded the trust target of 90%. Staff received training appropriate to their role and new staff were supported with structured induction and preceptorship programmes.

All staff who could be exposed to radiation were provided with radiation risk training. Across the diagnostic imaging business unit, the completion rate for this was at 86% which fell below the trust’s target of 90%. However, this was a trust wide figure and at Queen’s Hospital most staff groups had achieved over a 90% completion rate except for ultrasound (81%), trust wide registrars (79%) and trust wide radiologists (84%). As the data was trust wide it is unclear what the exact compliance was in Queen’s Hospital.

The trust was rolling out training on supporting autistic people and people with a learning disability.

Out‑of‑hours CT on‑call cover was recorded on the trust’s risk register. A reduction in available staff had made it increasingly difficult to maintain the rota. To manage this and ensure that patient safety was not impacted the service was regularly relying on bank staff. We were told that, due to the growing overnight workload, a business case was being developed to replace the current on‑call model with a permanent night‑shift arrangement.

Reporting radiographers (radiographers who are specially trained to look at X‑rays and scans and write a medical report explaining what they show) were available 12 hours a day, six days a week, with an external provider supporting reporting outside these hours.

Staff told us that reporting radiographers were proactive in identifying poor imaging techniques and supporting colleagues to improve practice.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All departments within diagnostic imaging were visibly clean and tidy. Hand sanitiser dispensers were positioned at the entrance to each department, and posters promoted good hand hygiene. Staff kept cleaning records up to date and cleaned areas regularly. During our inspection, we observed good hand hygiene practice and staff were observed to be bare below the elbow. Adequate handwashing facilities were available across all areas.

Staff followed established processes to ensure the environment and equipment remained clean. ‘I am clean’ stickers were in use throughout the department, and we observed staff cleaning equipment between each use. Sharps bins were available where needed, and all bins we checked were dated, clean and not overfilled. Staff disposed of waste appropriately, and clinical waste was managed safely.

Regular environmental audits monitored cleanliness and infection prevention standards. These audits included checks on hand hygiene compliance. They also reviewed bed and mattress cleanliness. Treatment chair cleanliness was assessed. IPC assurance compliance was monitored. Couch cleanliness was checked. Transfer trolley cleanliness was also reviewed. Data provided during the inspection showed that between November 2024 and October 2025, the average audit score was 94%. Four areas scored below 90%: couch cleanliness in obstetric ultrasound (80%) and ultrasound (89%), and treatment chair cleanliness in obstetric ultrasound (67%) and X-ray (69%).

Regular cleanliness audits also took place, and all areas scored above 96%, exceeding the 85% threshold required to pass. Where issues were identified, the audits clearly highlighted the actions required.

Staff received infection prevention and control (IPC) training as part of the trust’s mandatory training programme. Depending on their role, staff completed either level 1 or level 2 training. Training data reviewed during the inspection showed that 99% of staff required to complete level 1 training were compliant, and 80% of staff required to complete level 2 training were compliant. However, only 33% of staff in the medical and dental group had completed level 2 training, which was below the trust target of 95%.

Most staff recognised the importance of preventing the spread of infection. They told us patients with known infections were identified and offered appointments at the end of the day to minimise risk. When a patient with an infection was due to attend, staff had access to appropriate cleaning materials and personal protective equipment (PPE). Staff were given sufficient time to clean equipment between appointments.

The service made sure that medicines and treatments were safe and met patients’ needs and preferences. Staff involved patients in planning, including when changes happen.

Staff followed trust and national guidance for the safe management of medicines, including controlled drugs. They stored medicines securely in most areas and ensured that storage arrangements met policy requirements. Staff monitored room temperatures where medicines were kept.

Staff followed processes for checking expiry dates, and all medicines that we checked were in date. Controlled drugs were stored in line with legal, national and trust guidance.

Medicines, including contrast media, were generally stored correctly and in line with trust policy. However, during our inspection we found contrast stored in an unsecured cupboard within a patient changing room in the mobile CT scanning unit. In addition, staff did not keep a log of contrast taken onto the mobile CT scanning unit, which meant the service could not fully track contrast used. This was raised with staff and leaders at the time and a review of the process was completed to reduce this risk.

Patient group directions (PGDs) were in place for radiographers and sonographers. A PGD is a written instruction that allows certain trained healthcare professionals to give or supply a medicine to a group of patients without each patient needing to see a doctor or prescriber first.