Nuffield Health Exeter Hospital

Updated 26 October 2016

Nuffield Health Exeter Hospital is an independent hospital, which is part of the Nuffield Health corporate group. It provides outpatient and surgical services to adults, children and young people from birth upwards.

The hospital had two wards with 37 inpatient beds provided in single en-suite rooms. There were a further six single rooms with shared toilet facilities, used mostly for day cases and children.

There were three operating theatres and an endoscopy/laser room within the theatre suite. There was a six bay recovery (post-anaesthetic) area in the theatre suite, with one being paediatric friendly. The hospital had 11 outpatient consulting rooms, a small pathology laboratory and an on-site pharmacy.

There were 11 consulting rooms, two cardio physiology rooms and three treatment rooms where procedures were performed under local anaesthetics. 

The diagnostic imaging service provided a range of general and specialist imaging services including plain x-rays, ultrasound, mammography and Magnetic Resonance Imaging (MRI).

Updated 26 October 2016

We carried out this inspection as part of our programme of independent healthcare inspections under our new methodology. The comprehensive inspection was carried out through announced visits on 10 and 11 May and 9 June 2016. We did not carry out an unannounced inspection.

Our key findings were as follows:

We rated the hospital as good overall, with surgery and children and young people's services rated as good in all domains. Outpatients and diagnostic imaging services were rated as good in responsive, caring and well led domains and requires improvement in the safe domain. We did not rate effective for outpatients and diagnostic services due to insufficient evidence being available.

• Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff.

• Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines. There was excellent multidisciplinary team working within the service.

• Patients were at the centre of the service and the priority for staff. Innovation, high performance and the high quality of care were encouraged and acknowledged. Patients and their relatives were respected and valued as individuals. Feedback from those who used the service had been exceptionally positive. Patients spoke highly of the approach and commitment of the staff who provided a service. Staff went above and beyond their usual duties to ensure patients received compassionate care.

• Patients received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with patients and their families.

• Staff understood the individual needs of patients and designed and delivered services to meet them.

• There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.

• All staff were committed to patients and their relatives and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the departments they worked in. They spoke highly of the culture and levels of engagement from managers.

• Staff worked in an open and honest culture with a desire to get things right.

Are services safe at this hospital/service

• The hospital promoted a culture of reporting and learning from incidents. Incidents were fully investigated with actions for improvement identified and put into place.

• The management of medicines and infection control was in place with audit tools used to monitor practice.

• Staff were clear about safeguarding practices and knew what actions to take if they had concerns.

• Records were stored securely and audited for compliance with protocols. However in the outpatients department some confidential information was left unattended in unlocked treatment/consultation rooms.

• Nursing and medical records had been completed appropriately and in line with each individual patient’s needs.

• Surgical safety checklists were completed as required and a modified early warning score system was in place to support staff to recognise a deteriorating patient.

• The service had not yet achieved  Joint Advisory Group (JAG) accreditation or Endoscopy Global ratings Scale (GRS)  for its endoscopy service.

• The provider had a compliance level of mandatory training target of 90%. Most mandatory training achieved 100%

• Equipment specific to children’s needs was available for use.

• Staffing levels met the RCN guidance on defining staff levels for children and young people’s services.

• Infection rates were monitored.

• In the outpatients department not all hand wash basins or flooring in clinical areas were compliant with Department of Health 'health building notes' (HBN) which give best practice guidance on the design and planning of new healthcare buildings and on the adaptation/extension of existing facilities

Are services effective at this hospital/service

• Needs were assessed and treatment was provided in line with legislation and using National Institute for Health and Care Excellence (NICE) guidance. Staff were aware of the guidance relevant to their area of work.

• Policies and procedures incorporating national guidance were in place and available to all staff. Staff knew where to access guidance and policies.

• Staff were trained to ensure they were competent to provide the care and treatment needed. Staff training and appraisal was ongoing. Consent to care and treatment was discussed and obtained in line with legislation and guidance.

• Patients had good outcomes as they received effective care and treatment to meet their needs.

• Regular audits were carried out to monitor performance against national patient outcomes and to maintain standards.

• Patients were at the centre of the service and the priority for staff. High quality performance and care were encouraged and acknowledged and all staff were engaged in monitoring and improving outcomes for patients.

• Children and young people’s needs were assessed and care and treatment was delivered in line with legislation, standards and evidence-based guidance.

• Staff skills and competence were examined and staff were supported to obtain new skills and share best practice.

Are services caring at this hospital/service

• Patient feedback about the service was positive. Patients said staff were kind, caring and supportive. We saw staff were kind and caring, their focus being excellent patient care. They praised the way the staff really understood their needs and involved their family in their care. Patients were treated as individuals. Staff described occasions when they had been flexible at short notice to ensure patients had their procedures carried out.

• Between July and December 2015 there were high   satisfaction scores (85% and above) with the NHS Friends and  Family Test

• Patients said staff were caring and compassionate, treated them with dignity and respect, and made them feel safe. Staff went above and beyond their usual duties to ensure patients experienced high quality care.

• Staff were skilled to be able to communicate well with patients to reduce their anxieties and keep them informed of what was happening and involved in their care.

• Relatives were encouraged to be involved in care as much as they wanted to be, while patients were encouraged to be as independent as possible. They were able to ask questions and raise anxieties and concerns and receive answers and information they could understand.

• We observed staff treating patients with kindness and warmth. They were polite, calm and reassuring. The departments were busy and professionally run, but staff always had time to provide individualised care.

• Staff talked about patients compassionately with knowledge of their circumstances and those of their families.

• Paediatric staff used age appropriate distractions for their patients to relieve anxiety.

• Comments from patients and their parents specified the positive effect staff attitude and approach had on their stay.

• Staff responded to parent’s and children’s emotional needs by recognising and responding to anxieties. They did this by providing information and reassurance appropriate for age and understanding.

Are services responsive at this hospital/service

• Services were planned to meet patients’ needs. The flow of patients through the hospital was well organised. Patients felt well informed about the procedure and what to expect during their recovery.

• Services were tailored to meet the needs of individual patients and were delivered in a flexible way.

• Complaints were responded to in a timely manner and any  learning was taken forward to develop future practice. Staff actively invited feedback from patients and their relatives and were very open to learning and improvement.

• There was level access into the building and a passenger lift to all floors ensuring patients could move around the building.

• The hospital had reviewed the quality of the service and made reasonable changes where required, to ensure they could provide a safe service in a way that would suit the needs of children and young people.

• Where young people may feel sensitive about a procedure, arrangements were made to provide an advocate who was independent of their family or professionals providing direct care.

Are services well led at this hospital/service

• The hospital had a vision for developing the service and shared this with their patients.

• There were clear governance processes in place to monitor the service provided.

• Risks were identified and ways of reducing the risk investigated. Any changes in practice would be introduced, shared throughout the hospital and monitored for compliance.

• Leadership at each level was visible. Staff had confidence in leadership at each level and felt they would be listened to.

• The leadership, governance and culture were used to drive and improve the delivery of high-quality care. The clinical managers were committed to the patients in their care, their staff and the unit.

• Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

• There was a high level of staff satisfaction with staff saying they were proud of the departments as a place to work. They showed commitment to the patients, their responsibilities and to one another. All staff were treated with respect and their views and opinions heard and valued.

• Patients were able to give their feedback on the services they received; this was recorded and acted upon where necessary

• Actions were monitored through audit processes and reported to leadership and governance committees.

• The service ensured they were using skills and experience of organisations and specialists independent of the hospital.

Importantly, the provider MUST take action to:

• Ensure the outpatient department was cleaned effectively.

• Make sure the flooring and clinical hand-wash basins in the outpatient department complied with infection prevention control in accordance with Health Building Note (HBN) 00-09: Infection control in the built environment.

The hospital SHOULD take action to:

• Continue to investigate and monitor the occasional infestation of cluster flies in the roof space above the operating theatre.

• Continue to ensure staff complete mandatory training as required to reach the organisations target of 90% compliance.

• Ensure there was a decontamination policy for laryngoscope handles and blades in line with the Medicines and Healthcare Products Regulatory Agency (MRHA) Alert 2011.

• Gain Joint Advisory Group (JAG) accreditation or Endoscopy Global ratings Scale (GRS) (recognition granted to organisations which meet standards that require continuous improvement in structures, processes and outcomes) for its endoscopy service.

• Consider how children are protected from scald injuries wherever possible.

• Consider close monitoring of hygiene standards in all areas children and young people attend.

• Consider close monitoring of staff compliance with hospital protocols including chaperone policies.

• Closely monitor the cleaning of all areas to ensure they are dust free.

• Closely monitor compliance with hand hygiene protocol for all staff including consultants.

• Make sure all confidential records are stored securely.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 26 October 2016

• Investigations of incidents, comments and complaints identified where improvements were needed and these were acted upon wherever possible.

• A six monthly audit of the service reviewed safety and quality. National standards such as Royal College of Nursing (RCN) guidelines and National Institute for Health and Care Excellence (NICE) guidance were used as benchmarks. Gaps in service were identified and actions taken to develop systems that would meet the guidelines.

• Governance systems monitored standards of care and ensured appropriately trained staff cared for children and young people.

• Plans were being made to further improve the service in safety and responsiveness to children and young people’s needs such as using audit to ensure record keeping protocols were followed by staff and engaging patients and the public in assessing the service.

• All hospital staff were aware of when they would need support from registered children’s nurses or a paediatrician and how to access them.

• Children and young people had their individual needs assessed and plans were put into place to meet those needs wherever possible. This was to make their hospital stay less traumatic.

• Areas used were not dedicated solely for use by children and young people but were adapted where possible to make them more appropriate for any age of child. For example, beds for children and teenagers had different linen and activities were provided to entertain and distract all ages.

• Staff provided information for parents and for children in suitable formats.

• Parents we spoke with felt informed and that their children were treated as individuals.

• There was representation at leadership meetings and other committees throughout the hospital.

• Consultants were monitored for competency in their field of surgery and were required to provide evidence of their practice before being allowed to practice at this hospital. If consultants performed procedures less frequently at this hospital they had to provide evidence that they had performed these procedures in other settings such as NHS premises, on a more frequent basis.

Updated 26 October 2016

• Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff.

• Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines. There was excellent multidisciplinary team working within the service.

• Patients were at the centre of the service and the priority for staff. Innovation, high performance and the high quality of care were encouraged and acknowledged. Patients and their relatives were respected and valued as individuals. Feedback from those who used the service had been exceptionally positive. Patients spoke highly of the approach and commitment of the staff who provided a service. Staff went above and beyond their usual duties to ensure patients received compassionate care.

• Patients received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with patients and their families.

• Staff understood the individual needs of patients and designed and delivered services to meet them.

• There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.

• All staff were committed to patients and their relatives and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the department as a place to work. They spoke highly of the culture and levels of engagement from managers.

• Staff worked in an open and honest culture with a desire to get things right.

Updated 26 October 2016

• Staff were encouraged to report incidents. Learning was taken from their own incidents and those reported at other Nuffield hospitals.

• The systems in place to monitor patient safety including the World Health Organisation (WHO) surgical safety checklist were in place and well managed.

• Treatment was provided in line with national guidance and staff were aware of the NICE guidance related to their practice.

• Policies and procedures were in place to support staff and were available to all staff at all times.

• Staff had mandatory and role specific training to enable them to competently provide the care and support needed by patients.

• Feedback from patients and their relatives about the care provided was positive. Staff were seen to be kind and caring and provided individualised care.

• Services were planned to meet patient’s needs. The flow of patients through the hospital was well organised.

• Complaints were responded to in a timely manner and according to Nuffield Health’s policy. Learning was taken from complaints to develop good practice.

• There were clear governance processes in place to monitor the services the hospital provided.

• Managers were visible at each level, approachable and responsive. Staff had confidence in the leadership team.