Chartwell 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

The service did not ensure patient safety checks were completed in line with guidance. The service did not share lessons learned from incidents with staff. The service did not have an appointed magnetic expert/magnetic responsible officer. The service did not keep equipment clean and safe for patient use. The service did not always use effective systems to clean the MRI machine. However, staff had up to date mandatory training and all staff had up to date DBS checks. Patients told us they felt safe and supported in the environment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with patients who told us they felt well informed about their care and treatment and were involved in the decision making about their treatment.

The senior leadership team told us team meetings did not take place with the radiographers which meant lessons learned following incidents or complaints were not shared with the team. Therefore, there was no clear process for ensuring lessons were learned. There were missed opportunities to learn and improve.

During our inspection we could not see how the radiographers were encouraged or supported to raise concerns. The radiographers worked in the basement and were secluded from the rest of the service.

Staff knew what incidents to report and how to report them. Staff told us about the electronic incident reporting function and the process of investigating incidents. However, we were unable to see evidence that these were discussed at team meetings.

Not all staff we spoke with understood the duty of candour. Staff could not provide examples of what this meant in practice. Training records illustrated the service did not provide duty of candour mandatory training.

The service had an incident policy and staff we spoke with knew about this policy.

We saw the duty of candour policy was two years old at the time of inspection. The service provided a revised version of the policy during the data request stage.

We spoke with a patient who told us there was a lack of communication before the scan about how long the scan would take, how much noise to expect and the vibration during the scan. There was also a lack of communication during the scan about how long each sequence would take. Although staff told the patient the results would be sent to them within 6-7 days, there was no further information about what to do with the results or where else the report might be sent to.

Leaders told us they had a Radiation Protection Advisor from a local NHS Trust who was on site six months ago. However, the registered manager told us they kept in contact via email where necessary. The service however did not have an appointed magnetic expert/magnetic responsible officer. This is a legal role within the guidance for safety in magnetic resonance imagining.

Staff also told us they did not have a contactable medical physics expert or have any input with their day-to-day work.

The 5 Gauss line of an MRI suite defines a border to an area in which the magnetic field could affect implanted devices such as pacemakers. We saw the safety line had been drawn with a highlighter. Special warning signs about the strong magnetic field and its associated hazards need to be set up in the MRI facility. Magnetic fields above 5 gauss can affect pacemakers, implanted medical devices, and ferromagnetic objects, posing safety risks.

We spoke with the radiographers who told us they did not know who had drawn the line with the highlighter or how they determined where the line should be drawn.

We also saw there were no magnetic strength lines drawn on the diagram and staff told us no one has measured the magnetic field strengths to determine where the 5 gauss line is.

We spoke with staff about the 5 gauss line and one of the radiographers was unaware of what this was.

Following the assessment the service provided us with evidence that they had collaborative working with other organisations. The service provided us with a briefing paper for controlled drugs which was sent by NHS England South West local intelligence network for controlled drugs. The document provided by the service did not show any engagement from the service or demonstrate how they collabarated towards the briefing paper. Therefore we could still not be assured the service had any collaborative working between any other organisations.

We saw the patient group directive (PGD) for contrast which stated scans needed to be vetted by a radiologist at the chosen radiology reporting company or a radiologist at the specific hospital listed in the PGD. However, we did not see this practice and were told if the referring consultant had requested contrast, no vetting takes place and contrast will be administered. The service were not following best practice in relation to the safety guidelines for magnetic resonance imaging equipment in clinical use guidance.

We spoke with patients on the two days of our inspection who collectively told us they knew who to contact and how to raise concerns if they did not feel safe, or if they had concerns about the safety of other people.

Patients told us they felt safe and supported in the environment.

We were told the provider of the service would complete the recruitment process. The interviews and onboarding process was completed by the service. The service completed Disclosure and Barring Service (DBS) checks at the beginning of new starters employment and obtained updates during their employment. Managers would check staff members had the required competencies to complete their role. Managers ensured staff completed their mandatory training and were alerted to update training in advance of its expiration. Managers would hold yearly appraisals.

Staff had completed safeguarding training although the level of training was not known to staff. Discussion with staff demonstrated they did not always have a good understanding about safeguarding. This included how to identify patients at risk of or suffering harm from abuse or neglect. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service did not have access to mental health liaison and specialist mental health support. Staff did not always know how to care for patients who required mental health support.

Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. During conversations some staff demonstrated a lack of full understanding about the mental capacity act and Deprivation of Liberty Safeguards.

The clinical services manager was trained to safeguarding level 4 and was the lead for the service.

The service made sure new starters completed Disclosure and Barring Service (DBS) checks before they started in role.

We saw the safeguarding policy which was in date and had been ratified. The policy made reference to who the referral should be made to and the telephone numbers and emergency duty team.

We requested a mental health policy and were provided with the consent to endoscopy policy. The last version for this policy was version 4 and we could not see any other versions or changes that had been made to the document prior to this.

The service had a chaperone policy which was in date and had been ratified. The policy discusses how to safeguard the dignity, rights, safety and wellbeing of patients, consultants and staff throughout consultation, examination and treatment of care.

We spoke with patients who told us the booking process was straight forward and easy to use.

Patients told us they were involved with the decision making about their treatment. Patients knew who to contact if things went wrong.

Patients felt informed about the treatment they were going to have or had received.

We saw from patient records that all patients underwent a risk assessment and gave written consent to the diagnostic test before their scan. The department used an MRI patient safety questionnaire however risk assessments were poor and the ones that were completed were not fit for purpose.

Patient feedback forms were completed following the scan and handed to reception on their way out. The service then scanned these onto the system.

The service had three permanent radiographers and has access to a radiation protection advisor. Not all staff we spoke with were aware of how to contact the radiation protection advisor for concerns in relation to compliance with the regulations or incidents involving radiation exposure. They told us they would first consult with the registered manager.

Staff we spoke with did not know about the mental capacity act or the deprivation of liberty safeguards. Although the service generally saw healthy patients, staff could not give examples of what they would do if a patient required this support.

Staff we spoke with said they would not ask patients that had a male physical appearance if they were pregnant, even if this had not been completed on the safety questionnaire.

Staff within the department could not communicate clearly or provide coherent answers to the questions they were asked. For example we asked staff about the control of electron magnetic fields at work regulations (CEMFAW). Staff knew not to go into the scan room but were unable to provide information about the do’s and don’ts on being in a static magnetic field area. We could not see any information about those regulations written down anywhere in the service. We could not be assured this information was passed to new colleagues.

Therefore, we were not assured the staff could keep patients informed about any risks and how to keep themselves safe.

The service did not complete patient safety checks per guidance. Staff reviewed the MRI patient safety questionnaire but did not confirm patient details, including name, date of birth, address, clinical information, or the body part to be scanned. Additionally, there was no verbal patient identification confirmation when transferring patients between staff members. Patient forms were handed over without clarification.

The service had an MRI protocols folder, including an MRI protocol from the local NHS trust, last revised in 2022, but this was not customized for the service and lacked a review date. Another set of protocols from the NHS trust dated August 2021, and protocols from Basildon Hospital dated October 2021, were used for NHS patients, though those contracts were terminated. The protocol for the service’s patients was embedded in the MRI scanner software, not documented.

An in-date deteriorating patient policy was in place, stating that emergencies would require a 999 ambulance call. The MRI department, located in the basement, had stair and lift access. However, staff gave inconsistent responses when asked about emergency procedures, indicating unclear roles in an emergency scan scenario. No practical emergency drills were provided, and no written evacuation protocol was available.

The service offered remote scan reporting, sometimes sending reports directly to patients or the listed medical professional, such as a GP, physiotherapist, or chiropractor. If sent only to the patient, there was no follow-up to confirm patient understanding or if additional scans were needed. Unexpected findings were not explained, leaving patients without clarification on results.

Patients told us the patient waiting room was spacious and patients were able to follow the signs to get to the MRI area by lift or stairs. Patients told us the service had suitable facilities.

The registered manager identified the building reconstruction as one of the top three risks for the service. Following a flood in 2022, the service had made improvements to the building however still required some changes to be made.

We were told one of the top priorities was to fix the boiler so the premises could have heating. At present the service had thermostatic taps and used electric heaters for heating. We could not see any action plan to fix the boiler.

We spoke with staff about the emergency alarms and the patient call bells within the MRI department. The radiographers told us they thought it was their responsibility but had never tested them and were unaware of anyone else that had tested these alarms. We asked to see records of the testing of these alarms but staff were unable to show us any records. Staff however did check the handheld buzzer in the MRI scanner.

We found that cupboards on the ground floor containing electrical components labelled “fire door keep locked” were unlocked. We reported this, and the doors were subsequently locked. We observed the same issue on the first floor; again, we reported it, and the doors were locked.

In the waiting area, we noted MRI patient information leaflets and scan information on the walls. Patients had free Wi-Fi, as well as access to hand gel and a COVID QR code. While patients could listen to music during their scans, the waiting area speaker was not in use due to staff being unsure how to operate it.

The MRI scan room door had warning signs, but there were none in the waiting area, such as magnet or pregnancy warnings. The MRI control panel required staff swipe access, an improvement from the last inspection. All PAT testing had recently been completed by an external company, and service agreements were in place for larger equipment.

We found three staples in the MRI machine, which posed risks of image artifacts and potential injury to both patients and staff. Although we informed radiographers, no immediate action was taken.

Cannulations were performed in the MRI reception area, but there was no suitable chair with an armrest or the ability to lay patients flat if they fainted. Although the service had an x-ray tube and table, staff reported it hadn’t been used in 3–4 years, and there were no signs indicating it was out of use.

The CT room was being used for storage, leaving minimal space and making the sink inaccessible. Staff indicated the CT scanner was not in use.

Handwashing facilities were adequate throughout the service. Coffee facilities were out of order, and no other refreshments were available for patients. The COSHH cupboard was securely locked and properly stocked, but risk assessments regarding the MRI phantom containing COSHH substances were not completed.

We saw quarterly cleaning audits for the whole hospital for January 2024, March 2024 and June 2024 which were all 100%.

We saw the cleaning audits for the MRI area in the basement for 30 January 2024 which was 100%. We also saw the cleaning audit for 21 June 2024 which was also 100%. We were not provided with any other audits therefore could not be assured the service were frequently completing cleaning audits for this area.

There were three radiographers employed full time. We were told there were three bank radiographers that would cover for sickness and annual leave. However, staff told us the service had not used bank radiographers for the last three years. If there were insufficient staff members due to sickness or annual leave, the service would cancel lists. The radiographers told us they worked overtime to cover hours and, in some instances, worked more than 80 hours a week.

Two of the radiographers were trained to do the contrast injections. We were told the other radiographer will be completing the IV cannulation and drug therapy course to administer contrast injections also. Contrast injections could only be administered if there was a doctor on-site for the endoscopy list. The radiographers would need to ensure there was an endoscopy list that day before administering any contrast.

We spoke with leaders about their staffing. We were told many staff members left the service after the decision by the ICB to suspend the service for a period of time in 2023. The service had 22 members of staff in 2023 and currently had 14 members of staff. Due to the decrease number of patients from 2023, there were no plans for the recruitment and retention of staff.

The service was adequately staffed to ensure patient safety.

We saw staff working well within their department teams however there was no integration between the staff in MRI and the staff upstairs in endoscopy. The radiographers would ensure there was a doctor on-site by checking the lists prior to administering any contrast injections.

All staff had received a full induction and understood the service. All new staff were supervised and required to complete competencies before they were able to work independently.

Bank staff were required to complete an induction process, clinical competencies and mandatory training.

The service had remote reporting of scans by radiologists all over the country. We were told the lead radiologist was based in London and was available by telephone.

Patients told us they thought the environment was clean and they were happy with the facilities.

Leaders told us they had a contract with an external company to provide cleaning services twice a year. The legal contract for this service was requested but not provided. We were told at the data request stage the service do not have a contract with the external company and use this service as and when they require. We saw evidence of the last deep clean being completed in May 2024 .

We spoke with staff who told us the service had a cleaner. The cleaner worked at the premises from early hours in the morning until 10.30/11am. We saw cleaning charts in the reception toilets that showed the cleaners signature at 4.30am.

Staff told us when the cleaner was off on annual leave or sick, they would be required to clean. Otherwise, staff were unaware of who would complete the cleaning in the cleaners absence.

We were told the heating system was still not working. The senior leaders told us there were plans to fix this. We saw the action plan for the estates rectification plan however there was no mention of the heating system being repaired.

The reception area and communal areas were visibly clean.

Hand washing facilities were available in clinical areas. Reception staff ensured patients and visitors used sanitising gel on arrival.

Staff were ‘bare below the elbow’ however we did not see staff washing their hands or using hand sanitiser between patients.

Clinical waste was stored in a secure compound next to the building. The service had a clinical waste collection service level agreement which was signed in 2019 and agreed for a 24 month period. The service told us this was a rolling contract but we did not see any official evidence of this.

The hospital had suffered a severe flood in April 2021 and the diagnostic imaging department was badly affected, however we could see there had been some improvement in the environment. However, we could see some plaster had fallen off/was peeling off from the ceiling in the waiting room.

On the day of inspection, we saw the cleaning schedule on the inside of the patient accessible toilet had been completed in full and was up to date. However, equipment was not kept clean and hygienic. We saw the bore of the magnetic was dusty and we found 3 magnetic staples. We spoke with staff members about this, but they could not explain how the staples had got into the bore of the magnet.

We were told the cleaner would clean all areas including the MRI machine. There was a separate cleaning cupboard for the equipment used in MRI.

The radiographers told us they would clean the bore of the magnet with clinical wipes and lean into the bore of the magnet to clean it rather than using an extended duster with clinical wipes at the end to clean it. The registered manager told us the radiographers, following the inspection, had bought a duster to clean the bore of the magnet. However, they had not undertaken any further training in how to clean the magnet with the correct equipment.

Following the inspection, we requested cleaning audits for the service for the last six months. The service provided one cleaning audit for MRI which was completed in June and scored 100%. We could not be assured the service was cleaning the MRI area properly.

Infection control policy was in date and had been ratified. However, the scope of the policy indicates the infection control arrangements must be approved and assessed by the infection control advisor and other relevant staff. However, we were not told or had any knowledge of who the infection control advisor was. The policy also had links to websites that did not work and showed an error page when following the link.

We saw the lone worker policy which was in date and had been ratified. The policy stated wherever possible, the service will ensure that the norm should be that staff do not work alone. However, we were aware that the cleaner had been working at very early hours of the day at the service on their own. We had not seen any risk assessments or any implementation of a safe system to ensure the safety of the member of staff.

People’s medical history including currently prescribed medicines were reviewed on referral to the service. This ensured that the service was able to meet people’s individual needs prior to accepting them for referral to the service. People were provided with easy to read and understand information about their medicines and were guided through the process by knowledgeable staff. People’s capacity and consent was reviewed on entry to the service however there had been occasions where a person’s right to refuse certain medicines had not been fully considered by the team providing the care. The service had taken steps to ensure this would not occur again.

Staff were suitably trained to administer medicines throughout the organisation. Staff underwent routine competency checks and learning to manage and maintain their skills. Staff were in the process of being upskilled to undertake screening of people’s healthcare records and authorise them for treatment, however at the time of the inspection this could only be conducted by one person. Staff conducted a daily huddle where they could discuss about that day’s patients list and any learning or concerns that should be reviewed by the service.

Medicines were stored safely and secure. We observed that each area where medical or diagnostic procedures took place had access to appropriate resus equipment and emergency medicines. Checks were completed on these regularly.

The provider had medicines management policies and procedures in place. They worked alongside their supplying pharmacy to ensure medicines were stored safely and processes were followed.

Administration records were not always being completed accurately with doses sometimes missing and administration signatures, especially around controlled drugs, not being completed in line with best practice recommendations. The service was missing a waste exemption certificate that is required to denature and destroy controlled drugs. Current patient group directions (PGDs) which allow nursing staff to supply medicines to specific patient groups were not up to date. We raised these concerns at the time of the inspection and the provider has taken steps to change or improve practice and reduce the impact of the concerns we identified.