Nuffield Health Exeter Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as good. However, it was combined with the outpatient’s department and was under a different methodology. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patients and their communities.

The provider was a health and wellbeing charity who saw their purpose to improve the health and wellbeing of the nation. This was underpinned by 5 ambitions. Managers and staff were aware of their purpose and wanted to provide an excellent experience for people using the service.

The service had developed a radiology strategy based on the provider’s purpose and ambitions. Each ambition had specific radiology goals to improve the service. The ambitions were built into the appraisal process. The staff survey carried out in December 2025 showed that staff felt goal setting was a strength of the service. However, their mission and strategy was an area to make improvements on. Managers told us they monitored complaints and incidents to understand if the service was meeting their purpose.

The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive, and they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration within the service. The staff survey carried out in December 2025 show staff felt peer relationships were very good.

Staff said they generally had good relationships between different services in the hospital. However, there were times where they felt staff from another area spoke to them in an unprofessional manner.

Leaders spoke to us about the importance for staff to develop skills and were supportive of staff to seek any development opportunity.

Team and Individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work. Service leads recognised staff’s work and contributions during daily huddles.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

The overall lead for the diagnostic imaging service was the radiology manager. They understood the service, how it operated and the role of imaging in improving people’s health and wellbeing. All staff we spoke with told us they were well supported by their manager and were confident in the in how the service was being led.

Staff told us that senior leaders of the hospital were visible and approachable for patients and staff.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns; the culture allowed staff to be confident their voices were heard.

The service had a freedom to speak up policy which identified roles and responsibilities of staff and provided guidance on raising concerns. Staff had access to 2 freedom to speak up guardians and knew who they were. Staff told us they would approach their line manager about any concerns but felt if they used the freedom to speak up process their concerns would be taken seriously.

Staff had confidence leaders would investigate concerns sensitively and confidentially.

The provider’s website detailed how people could raise a concern and how this would be investigated. There were complaint escalation routes for private and NHS funded care. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

Staff received training in freedom to speak up. Records showed that 90% of staff had completed this training.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

The provider had colleague networks for specific groups of people. The purpose of these networks was for staff to share their experiences and make improvements to the workplace.

The service had an in date equality, diversity and in inclusion policy. Staff told us leaders worked to create an inclusive working environment. We observed leaders being approachable and supportive to all members of staff.

The hospital had a room that could be accessed by staff wanting to pray or have space for quiet reflection. This doubled as the well-being room.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service could not always be assured that they monitored the safety of the service in line with best practice. The service did not have any local ionising radiation protection committee meetings. This is not in line with best practice or the provider’s policies. The service said these meetings were not occurring due to changes in key personnel. There were plans to introduce the radiation protection committee when arrangements were finalised in March 2026. This meant that radiation safety issues may not be identified and acted upon in a timely way.

Governance arrangements were not always effective. Whilst there was a system to monitor the safety of the service, this did not identify some key areas of concern found during our assessment. For example, radiation signage missing from the x-ray room door, labelling of fire extinguishers in the MRI room, or local policies and rules containing incorrect information.

Governance arrangements at service level fed up to the hospital wide governance system. There were regular meetings involving key service managers, which provided them with oversight of risk at both a departmental and corporate level.

There was a medical advisory committee (MAC ) that met regularly to ensure patient safety, quality care and regulatory guidance. This discussed incidents, adverse events as well as approving practicing privileges for consultants. We spoke with the chair of the MAC committee who said there was good consultant engagement with the committee. We reviewed consultant practicing privilege files and saw there were robust governance processes to ensure consultants submitted the necessary documentation to ensure safe care for patients. Practising privileges were reviewed every 2 years. Practising privileges allow medical professionals to provide specific clinical services within the organisation without being directly employed by the organisation.

We reviewed several provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities.

The provider had oversight of the performance of the third-party CT image provider.

Leaders made sure that accurate information was discussed and shared with key staff. Staff felt well informed on key issues and performance.

Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations. The services local risk register held relevant risks to the service. This linked into the hospitals risk register; Risks were reviewed regularly.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to changes.

The service had a business continuity plan which would be put into operation in the event of an unexpected disruption to the service, this included a short-term disruption plan.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff shared information and learning with partners and collaborate for improvement.

The hospital ran free of charge events where the public could attend presentations on a variety of health topics. This could be booked on the provider’s website.

The provider was chosen to support a major international sports tournament in 2025. Nuffield Health Exeter Hospital was involved in supporting players based in the local area for the event. The radiology department was involved in providing an imaging service for the teams.

The service was planning a radiology conference to share information on radiology services and safety.

The hospital had a program of fundraising events to support their chosen charity of the year.

People who used the service felt care and treatment was well co-ordinated, and staff engaged with them to keep them informed about their scan procedure and the reporting of scan results.

The service focused on improvement across the organisation. Staff actively contribute to safe, effective practice.

There were processes for learning when things went wrong and for sharing good practice, either locally or nationally. We were told about an MRI quench incident (the rapid release of liquid helium causing the magnet to lose its magnetic field). Staff used this incident to share leanings and improvements with the provider’s other diagnostic services.

The service reviewed and invested in equipment to improve service delivery. For example, they introduced automated technology for the high-level decontamination of ultrasound probes. They also took delivery of a new mobile x-ray scanner in October 2025.

The service had plans to expand imaging provision. There were business cases for areas of expansion to meet future demands.