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 good. At this assessment the rating remains 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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. Staff were able to identify and report risks and were assured they would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harm occurring.

Meetings (called SWARM) were held as soon as possible after a patient safety incident occurred. These were collaborative multidisciplinary team meetings to gather information and assess what went wrong, identify system-level improvements, and prevent recurrence.

We saw evidence incidents were investigated and actions taken to reduce the risk of recurrence. They were discussed at weekly review meetings and monitored by senior management. Incidents were analysed to identify trends or themes. Staff received feedback from investigation of incidents. Managers debriefed and supported staff after serious incidents. Learning was shared with other Nuffield Health locations.

There was an electronic system for managing incidents. We reviewed adverse event and incident reports showing when SWARM meetings were held, investigations were conducted and action plans produced if required. Staff understood duty of candour and the importance of being open and transparent with patients and families. We saw examples of duty of candour letters sent when appropriate.

Staff told us of an improvement in safety from an incident when the wrong side for an injection was identified. However, staff employed the “Stop before you block” (inject) protocol and the correction was made. This safety measure in anaesthesia aimed at preventing wrong side nerve root blocks had not previously been completed for nerve root injections. As a result of the incident “stop before you block” was to be used across all Nuffield hospitals.

The service reported no Never Events in the 12 months prior to our assessment (these are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed). During our site visit we reviewed a never event (from the previous year) which had been classified as an adverse event. The provider had decided not to classify it as a never event or serious incident and it had not been reported. However, duty of candour had been carried out and learning identified.

The service worked with people 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 people moved between different services.

The service’s referral and admission processes ensured all essential information about patients was received to determine if patients’ needs could safely be met. New patients who attended for review for surgery were now optimised at outpatient appointments and asked to complete health screening questionnaires. Optimisation is the process of preparing patients’ physical and mental health to the best possible prior to surgery. Staff completed several medical tests such as blood tests and electrocardiogram (ECG) to check on their fitness prior to attending the preadmission clinic. This was set up to reduce the number of surgery cancellations as problems could be identified prior to preadmission clinic. Patients could receive treatment or take appropriate actions to ensure operations were not delayed.

Patients were referred to the preadmission assessment clinic and reviewed against a set criterion. Depending on the operation, some patients could have a telephone preadmission assessment, and others were invited to attend the clinic. Staff assessed their suitability against the criteria. If required, staff could refer to the anaesthetist for review.

We followed patients from theatres to recovery and saw handovers from anaesthetists to recovery nurses and observed safe and effective communication.

Leaders were assured the World Health Organisation (WHO) checklists were completed in line with policy by completing quarterly audits. The last safe surgery audit of 10 sets of observations showed 99% compliance.

When overall responsibility for the care and treatment of patients moved to different service providers, such as transfer to the NHS, there was effective communication to ensure seamless transfers. There was a service level agreement (SLA) with the local NHS hospital to transfer patients if they deteriorated and intensive care was required. Patients’ documents were transferred with patients and verbal handovers from consultants to ambulance staff were completed.

The physiotherapy team provided a telephone number for patients to access support following discharge. Patients were also provided with information about their medication to take home, including contact numbers if they had any concerns.

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

Staff knew how to make safeguarding referrals and who to inform if they had concerns. Advice from safeguarding leads was available to support staff. Staff could also access a level 4 national safeguarding lead within the provider’s wider organisation.

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

We observed safeguarding posters during our visit. There was a safeguarding policy with details for training standards. Managers were confident staff could identify safeguarding concerns and considered safeguarding when an incident occurred.

Staff received training specific for their roles on how to recognise and report abuse. Staff also received training in learning disabilities and autism. Staff were trained in adult safeguarding and records showed permanent staff were 98% compliant for level 1 training and 93% compliant at level 2. Staff were 71% compliant for level 3 (there were 7 staff in total and 2 were new staff who had yet to complete their training which would equate to 100% compliance). Some leaders had also completed level 3 safeguarding for children and young people. For more information on children and young people please see the children and young people’s assessment.

The service had an up-to-date chaperone policy of which patients were informed when they attended.

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 people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so they understood their care and treatment. We saw staff providing explanations to patients at different points in their surgical pathway and patients told us they were well informed.

We reviewed 5 sets of patient records, and all were completed as required, including venous thromboembolism (VTE) risk assessments, pressure ulcer risk assessments and nutritional risk assessments.

There were monthly audits to provide assurance that National Early Warning Score observations were conducted (NEWS2 is a nationally recognised tool to identify deteriorating patients and escalate them appropriately). Observations included sepsis screening and escalation if patients showed signs of deterioration. Data for November and December 2025 showed the service was 99% compliant in completing the audit.

The monitoring of sepsis was taken very seriously. There were 2 sepsis boxes containing appropriate equipment which was signed and dated. On discharge patients were given information cards regarding what to look out for and who to contact in the event of feeling unwell.

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

The service had a process to check the safety of electrical equipment. We checked equipment on the surgical ward and found all items were in date and PAT tested (portable appliance testing to check electrical appliances for safety through visual inspections and electronic tests). Gym equipment was also PAT tested and service checks were all in date.

Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. We observed fully compliant resuscitation and airway trollies in theatres and recovery.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the service’s policy. We observed theatres bins were compliant. Sharps (medical instruments with sharp points such as blades and needles) bins were managed safely and were fully compliant. Chemical or substances hazardous to health (COSHH) were stored safely and information about products was available to staff. Risk assessments were undertaken to check hot and cold-water systems for legionella bacteria and the October 2025 report showed none detected. We observed a suture cupboard in theatres where items were stored correctly and in date.

Fire exits were clear and free from obstruction. We also observed fire procedure notices, fire alarms and fire extinguishers. There was a nominated fire officer of the day. At the time of our assessment, service work was being carried out on one of the lifts and risks had been assessed and mitigated.

The facilities department employed an electronic application to monitor water hygiene including legionella control. This was compliant with safe water in healthcare guidance.

Wards, patient rooms and equipment appeared to be well maintained, free from clutter and visibly clean.

The service achieved the joint advisory group (JAG) accreditation for its endoscopy service. The JAG accreditation is the formal recognition an endoscopy service has demonstrated its competence to deliver against the measures detailed in the endoscopy standards. There was now an air cupboard to dry endoscopes after cleaning.

Environmental audits were conducted in theatres and wards with recommendations for improvements, such as to replace the flooring in the staff rest room. There were comprehensive cleaning schedules and tasks for each department, ensuring deep cleaning on a regular basis at weekends. Theatre cleaning audits showed mainly 100% compliance.

Patients we spoke with said the environment appeared clean and well-maintained. However, one patient said they thought it was “slightly dated”, although clean and tidy.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’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. New staff underwent full inductions when they joined the service. The service had no vacancies at the time of our assessment. Theatre staffing levels followed guidance set out by recognised professional bodies.

Weekly capacity meetings were utilised to ensure theatre lists were booked appropriately and ahead of time to allow planning of staff, adjust staffing levels as required and to prepare patients.

The safer nursing care tool (SNCT) and National Institute for Health and Care Excellence (NICE) guidelines suggest acute wards should have a ratio of 1 nurse to no more than 8 patients with regard to the risk of patient harm. Leaders told us the surgery ward had a staff ratio of 1 nurse and 1 health care assistant (HCA) to every 6 patients to safely accommodate patient needs.

When necessary, managers deployed agency nursing staff to maintain safe staffing levels. There were a few examples when agency nurses were required to cover shifts.

Staff had received and were now up to date with appropriate mandatory training. Data provided showed 96% of permanent staff had completed mandatory training (the level required was 90%). The compliance figure for permanent combined with bank staff, who completed the same training, was 94% compliant. Most bank staff worked at the local NHS hospital. Training was appropriate for the patient group using the service.

If there were cancellations due to staff sickness, patients would be rebooked on the day when possible. There was a low level of staff sickness and patients did not have long waits when rebooked. At the time of our inspection there was only a 5% sickness rate for ward and theatre staff.

There were resident doctors (RDs) providing 24/7 on-site medical care and acting as a link between patients and consultants. Staff told us consultants were always contactable during evenings and weekends.

We reviewed recruitment files and found the service was compliant with Schedule 3 of the Health and Social Care Act (HSCA) 2014. The service carried out recruitment checks and there was a process to check all staff had up-to-date enhanced disclosure and barring service (DBS) checks and, where applicable, had kept their professional registrations up to date. Bank staff followed the same recruitment and DBS processes. The electronic system would flag if these were out of date.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading,

There was a provider infection prevention and control (IPC) policy and supporting guidance which was accessible to staff. Staff completed training in infection prevention and control and management of sharps. We saw staff following infection control principles including compliant handwashing and the use of personal protective equipment (PPE). Antibacterial hand wash was available along the ward corridors and we observed staff in theatres using the wall mounted dispensers to disinfect their hands. There were in date “I’ve been cleaned” stickers on all the equipment we observed including on the sinks in vacant patient rooms. However, some basins were still non-compliant with regulations as they had overflows plugged with small silicone bungs. This was raised with the facilities manager at the time. Leaders told us there was a programme for environmental improvements.

Hospitals are required to report infectious diseases, including methicillin-resistant staphylococcus aureus (MRSA) and clostridioides difficile infection (CDI). Data provided showed there were no occurrences of reportable infections during the year 2025. Surgical site infections (SSIs) in hospitals are infections occurring after surgery. Data provided for 2025 showed 4 SSIs recorded, spread across the year.

Each department had an IPC lead responsible for the area. Housekeeping had comprehensive cleaning schedules and tasks for each department, ensuring deep cleaning on a regular basis with bank staff employed at weekends. There were cleaning policies and audits were completed with spot checks. Housekeepers were aware of their duties and responsibilities. The hospital followed the national cleaning standards 5* rating system. However, in theatres we observed the use of cleaning wipes which were non-compliant with guidance. This was raised with staff at the time, and the correct wipes were ordered.

Housekeepers completed window restrictor, mattress and curtain audits ensuring curtains were changed every 6 months. Information was documented electronically and shared with the national manager. We also observed sluice rooms which were fully compliant. However, in the “dirty” utility room we observed a bottle of bleach which was unlabelled and had been decanted from a larger bottle. Staff were informed who said they would deal with it immediately.

We observed 1 storage cupboard which was small and the shelving inadequate. Boxes containing disposable cups, mops and other cleaning items were stored on the floor making it difficult to clean under the shelves and keep items clean. We raised this with staff and actions were taken to clean and remove supplies from the floor.

There was a programme of infection prevention and control audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas. Hand hygiene audits were now performed across the hospital and compliance for the 3 months July, August and September 2025 was 100%.

There was still a continued problem with the occasional infestation of cluster flies in the roof space above the operating theatres which was being managed with fogging and fly screens. This was due to the nature of the surrounding environment external to the building.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish was not worn and staff in clinical areas were bare below their elbows to allow full hand decontamination. However, we observed some staff in theatres wearing necklaces which was contrary to the uniform policy. This was raised with the management team who told us some staff wear necklaces for religious reasons and they would review the policy wording.

There was a decontamination policy and the service was fully compliant with the decontamination process for flexible endoscopes. There was now a decontamination policy for laryngoscope handles and blades in line with regulatory guidelines. Blades were now disposable and handles were reusable. Instruments were sent to the service’s purpose-built facility specialising in the decontamination, cleaning, inspection and sterilization of surgical instruments in compliance with decontamination guidelines. Instruments were collected and delivered several times a day.

We observed the service still had carpet flooring in some areas. However, we were informed measurements had been taken and carpet replacement would commence in May 2026.

The environment now appeared clean and dust free. Patients told us the environment looked clean and tidy. However, we observed cleaning trolleys containing disinfectant left unattended in public spaces. We raised this at the time and action was taken to store trolleys in cupboards when not in use.

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

The service had safe systems for the appropriate and safe handling of medicines. There were processes to ensure people received the medicines they needed.

Staff followed national practice to ensure they had a complete medical history and list of current medicines the patient was taking prior to any surgical procedures. This aided decision making on any medicines changes which might be required prior to surgery and reduced the risk of cancellations and delays.

Patients were given verbal and written information about their medicines prior to and post any surgical procedures. We saw examples where patients had been involved in the production of written materials to ensure these were truly patient friendly resources.

There was a system of medicines audits and we saw examples of changes being made to practice because of these. The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts.

We reviewed an emergency trolley in the recovery area. There was a system for daily checks, and we found the records were fully completed. All items were present and in date.