Nuffield Health Exeter 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 people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question as requires improvement. However it was combined with the outpatient’s department and was under a different methodology. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

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. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service had a current incident policy, which reflected the provider and national guidance.

We saw evidence of incidents having been investigated, and action taken to reduce the risk of recurrence. We looked at the system for managing incidents which was electronic. In the 12 months prior to our assessment there were 34 incidents and near misses reported. All incidents were reported as low or no harm to people.

There had been 0 reported incidents requiring reporting under Ionising Radiation (Medical Exposure Regulations (IR(ME)R). Providers must report incidents where a patient receives a much greater dose of radiation than expected.

There had been 0 reported never events in the 12 months prior to our assessment. Never Events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harms occurring.

Incidents were analysed to identify trends or themes and potential links to individual practitioners. There had not been any repeated themes or trends in the 12 months prior to our assessment.

Staff understood the duty of candour. They understood the importance of being open and transparent with patients and families. Staff received feedback from the investigation of incidents.

There was evidence that changes had been made because of feedback, such as improving safety of the MRI scanner following a quench (rapid loss of magnetic field) incident. Learnings were shared with other Nuffield Health locations. Managers debriefed and supported staff after any incident.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

There was an admission criterion for both private and NHS patients. These criteria set out where they had who could be seen safely at the service. For example, there were restrictions on bariatric patients for certain scans. However, the service would refer these patients to another hospital operated by the provider.

There were systems and processes to ensure the correct patients were treated throughout the patient journey and they only received the procedure which was intended. Suitably skilled and qualified staff accompanied patients in all areas and undertook the required diagnostic procedure.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. The service used The Society of Radiographers “Pause and Check” system. Pause and check consisted of the 3-point check to correctly identify the patient, as well as checking with the patient the site to be imaged, the existence of previous imaging and for the operator to ensure the correct imaging modality was used. We observed staff always using the 3-point demographic checks in line with the correct procedure.

All patients were required to complete MRI safety questionnaires. The safety questionnaires included asking patients if they had cardiac, defibrillators or other devices in their chest and patients were asked if they were pregnant. We saw these were completed. Other visitors such as family members were asked to complete a visitor’s safety questionnaire prior to the scan. Gowns were available for patients to change into if their clothing contained metal, such as metal zips. All referrals included patient identification, contact details, clinical history the examination requested, and details of the scan referrer.

The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer. All patients we spoke with understood how they would receive results.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

In the 12 months prior to our assessment, there had been no safeguarding concerns raised to the local authority. Managers were confident that staff could identify safeguarding concerns. They said they also considered safeguarding when an incident occurred or complaints raised.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 2 for safeguarding adults. Records showed that the service had 85% compliance for the training. Managers understood the reasons for uncompleted training and there were plans for this to be completed. Staff were trained to level 2 for safeguarding children and young people. Records showed all staff completed the training. For more information on safeguarding children and young people, please see the services for children and young people’s assessment.

Staff received training in learning disabilities and autism.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff. Staff could access a level 4 trained person within the provider’s wider organisation.

The service had an up-to-date chaperone policy, which all patients were informed of when they attended the service. There were chaperone posters in the department. Records showed that staff noted when a chaperone was used. However, not all staff understood the role of a chaperone. The primary role of the chaperone is to assist the clinician undertaking the procedure in supporting the patient and to act as the patient’s advocate, being sensitive to their needs and respecting and maintaining their privacy and dignity.

The service carried out appropriate recruitment checks. This included checks with the Disclosure and Barring Service (DBS) for both adults and children barred lists. There was a process to review risks identified in recruitment checks.

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

The service worked with patients to understand and manage risks. The treatment and care met patients' needs in a way which was safe and supportive.

Staff communicated with patients so that they understood their care and treatment. We observed staff providing an explanation of an MRI procedure and confirmed that they understood the procedure. Patients told us they were well informed.

The service had pregnancy status forms for all patients to complete aged 12 to 55 regardless of their gender. This was to prevent accidental radiation of exposure for all patients capable of being pregnant.

We spoke to 16 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

The resuscitation trolley situated between the outpatient department and the diagnostic imaging department had daily checks undertaken. Paediatric and adult resuscitation policies were available as well as resuscitation council guidance. Staff received training in life support.

Patients could summon assistance and help as needed through the use of call bells and we saw patients were shown this. There were emergency alarm cords in changing areas.

There was a process for dealing with a medical emergency within the MRI scanner. Staff had successfully evacuated patients 3 times in the 12 months prior to our assessment.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not always make sure equipment supported the delivery of safe care or that there was appropriate mitigation of the risk.

The x-ray room did not have permanent signage warning of the risk of ionising radiation exposure should a person enter the room un-authorised. This means people could have been at risk of unintended exposure to ionising radiation. After our onsite assessment the service provided evidence signage had been put in place.

Staff did not know if some fire extinguishers could be used in the MRI room in case of a fire. The MRI area had 2 fire extinguishers that were not labelled showing if they were safe to use in MRI areas. Equipment used in the MRI room must be safe to use near a static magnetic field. The Medicines and Healthcare Products Regulatory Agency (MHRA) recommend that no equipment should be taken into the MRI area, particularly the magnet room, unless it is safe or can be used in specific conditions. After our onsite assessment the service added the appropriate signage on the extinguishers.

We checked the equipment and found some single use items were out of date. We found 10 packs of sterile gel and 1 pack of sterile gloves out of date. These items may not be as effective when used.

The service did not have a plan to practice evacuation of the MRI as recommended by MHRA. However, staff had successfully evacuated 3 patients in the 12 months to our assessment. Staff said this made them well practiced in evacuations. The service put in a plan during our assessment to complete evacuation drills.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment.

The design of the environment followed national guidance around the built environment. Access to examination rooms was restricted by a keypad lock.

MRI local safety rules were in place and reflected best practise. There was signage which detailed the magnet strength and safety rules. The MRI scanners were fitted with emergency buttons which stopped scanning and switched off power to the magnet. There was a warning barrier in front of the door to the magnet room.

There was suitable equipment provided which was used correctly for patients who needed assistance with their mobility or to transfer onto scanners. Staff carried out daily safety checks of specialist equipment. There was testing of portable electrical equipment. Weighing scales were calibrated. There was ready access to resuscitation equipment in the department. There were emergency procedure sheets for the MRI scanners.

The environment used for patient care reduced the risk of patient harm, and included for example, safe flooring, handrails and window restrictors. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair or replacement of broken or missing equipment. Staff said they had access to spare equipment from other departments if necessary.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the provider’s policy. Sharps bins were managed safely.

Chemicals or substances hazardous to health (COSHH) were stored safely and information about products was available to staff.

The service had a process to visually check and test the effectiveness of lead aprons. The service monitored staff exposure to radiation.

At the time of our assessment, the hospital was having building work carried out. The service had assessed risks associated with the work being carried out.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service had leaders for x-ray, MRI, and mammography. The service deployed radiologists, radiographers, radiology assistants, assistant practitioners and administration staff. The service had 12 contracted staff (equivalent to 7 whole time equivalent) supported by 7 bank staff to cover imaging. There were 12 radiologists.

The service ran 8am to 6pm, Monday to Friday. Outside of these hours the service offered an on-call service to meet radiology service needs within the hospital. On-call staff were able to attend site within 40 minutes.

The service had no vacancies and at the time of our assessment, and no long-term staff absences.

New staff had a full induction when they started work. This included orientation of the service, responsibilities within the department, and competencies to use specific equipment. Staff said they felt the induction helped them settle into the hospital.

The service had challenges providing continued professional development opportunities. Staff survey results showed staff felt continued professional development needed improving. However, since the last staff survey had been carried out the service had made available online radiology learning presentations.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. At the time of our assessment 2 appraisals were not completed. However, there were plans for these to be completed.All radiologists were required to provide evidence of appraisal and re-validation. There were processes to deal with poor performance.

Medical staff were mainly employed by NHS organisations and had practising privileges to work within diagnostic imaging. Evidence was provided to demonstrate that all medical staff were up to date with General Medical Council registration, Disclosure and Barring Service status and indemnity insurance was in place.

Staff said they felt the service was safe. They were able to take breaks during their shift. Patients spoken with felt their needs were met in a timely way. They said staff were very professional and they felt safe in the service.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The department was mostly visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

The service had a new high-level disinfection system for ultrasound probes that allowed highly effective decontamination and traceability. Traceability is the documented record linking the specific probe to the decontamination history and the patient it was used on.

The service managed infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. Most equipment was visibly clean. However, a mobile scanner showed the presence of dust. There were some cardboard boxes stored on the floor under the x-ray control room panel which prevented effective cleaning.

There was a provider infection, prevention, and control (IPC) policy and supporting guidance that was accessible to staff.

There was a programme of IPC audits. For example, hand hygiene audits were performed as a sample across the hospital. In the most recent audits, the scores showed compliance with IPC measures in all clinical areas.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

We saw staff following infection control principles including compliant handwashing and the use of personal protective equipment (PPE).

Staff understood the process for managing spillage of body fluids in the department.

Staff supported IPC measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

Staff completed training in IPC and management of sharps.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

For each scanner the staff had access to required medicines and there were securely stored. Emergency medicines were kept in an accessible container. Medical oxygen cylinders were stored, staff told us these were administered under patient group directions (PGDs) (PGDs are legal frameworks that allow healthcare professionals to supply or administer specific medicines to a pre-defined group of patients without a prescription) and standard operating procedures (SOP’s). The service used systems and processes to safely prescribe, administer, record and store medicines.

Staff completed medicines records accurately and kept them up to date. There was effective governance of medicines.

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence.