Nightingale Hospital Exeter

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

This is the first assessment for this service. This key question has been rated requires improvement.

This means we looked for evidence that people were protected from abuse and avoidable harm.

Not all staff in diagnostic imaging had received an appraisal and a number of staff were not up to date with essential immediate resuscitation training. Senior staff were also unaware of some medicines management procedures which were not in line with best practice.

However, the service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. This meant people were safe and protected from avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 safety performance over time was good. Managers monitored the numbers of incidents at the Nightingale Hospital quarterly to identify any themes and trends and acted where necessary. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. All relevant staff, services, partner organisations and people who used services were involved in these reviews and investigations. However, we saw 1 incident where a patient had been given the wrong type of scan but saw leaders of the service had taken action to prevent recurrence.

Teams worked together to identify and share learning including dose optimisation. The service had effective arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations and reviews. The imaging service ensured unintended exposures and were notified to relevant regulatory bodies. At the time of our assessment there had been no reportable incidents.

Leaders and staff strived for continuous learning, improvement and innovation. The provider participated in the Quality Standards for Imaging (previously ISAS) accreditation schemes. Staff regularly worked together to resolve problems which led to improvements and better working relationships.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service carried out comprehensive risk assessments for people who used services and staff identified and responded appropriately to changing risks to people. There were procedures for the collapse of a patient in MRI, and staff were clear on the process for safely evacuating a patient, having attended a targeted session by the ALS training provider. However, these processes had not been practised although staff could describe how they would run and manage an evacuation.

Some clinical staff had received training in Immediate life support (ILS) and had access to an onsite team who were Advanced Life Support (ALS) trained. However, both level 2 adult and level 2 paediatric training compliance was well below the trust target at 54.8% and 51.7%. This meant some staff may not know how to respond in the event of a an emergency.

Staff followed processes to ensure the right person got the right radiological scan at the right time. Audits showed 100% compliance.

The service followed the Royal College of Radiologists standards for the communication of radiological reports and fail-safe alert notifications.

The service ensured that the radiation protection advisor (RPA) and the medical physics expert (MPE) were easily accessible for providing radiation protection advice. The service had Radiation Protection Supervisors (RPS) in the departments which used ionising radiation.

Staff identified patient risks using local policies which were in line with national standards and guidelines.

The service had clear local rules (Ionising Radiation Regulations) and employer’s procedures (Ionising Radiation (Medical Exposures) Regulations) which protected staff and patients from ionising radiation.

Staff followed national protocols to check and ensure requests for imaging procedures were appropriate for the patient. Where there were multiple IT systems, the service ensured information was shared and accessed securely when required.

Patients were provided with leaflets of ongoing advice after their procedure in a format they could understand.

There were positive and collaborative relationships with external partners and there was transparency and openness with all stakeholders about performance.

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.

The service shared safeguarding concerns quickly and appropriately. Staff, employed by the trust and by third parties, had received safeguarding training at the correct level for their roles and could identify when to report abuse and how.

Information regarding safeguarding from abuse, sexual safety and domestic abuse was displayed where service users could see it. Staff were able to access a named or designated professional for advice 24 hours a day.

The service had a chaperoning policy for children and young people that staff were aware of and understood.

Staff were trained and understood the relevant consent and decision-making requirements of legislation and guidance.

Managers monitored consent processes to ensure it met legal requirements and followed relevant national guidance. However, audit data showed only 33% of referrers had provided an explanation of the benefits and risks of having the radiation exposure before patients had the examination. This meant patient may not be aware of risks associated the radiation for the scans they received.

Staff had received training in Deprivation of Liberty Safeguards (DoLS). DoLS is a legal framework within the Mental Capacity Act 2005 in the UK. It is aimed helping protect vulnerable individuals who lack the mental capacity to consent to care or treatment arrangements that may restrict their liberty.

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.

The service identified and met the information and communication needs of people with a disability or sensory loss. Leaders ensured services were delivered and made accessible to take account of the needs of different people, including those with protected characteristics under the Equality Act.

The service carried out comprehensive risk assessments for people who used services, and these were reviewed every 2 years.

The service had clear local rules (IRR) and employer’s procedures (IR(ME)R) which protected staff and patients from ionising radiation.

Staff enabled patients to give feedback on the service they received. Patients we spoke with said they felt supported by staff. We saw evidence that patient choice was respected when deciding which treatment option to choose.

The hospital did not have an emergency department (A&E), however, if a patient became unwell, staff called 999 to request an emergency ambulance to take the patient to the main hospital. There was also a resident doctor on site who could be called to provide support to the patient until they could be transferred to the main hospital.

Resuscitation trolleys were easily accessible to staff in the event of an emergency. They were located throughout the main outpatient department and the specialty outpatient areas. The trolleys were fully equipped and checked regularly by staff.

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 design, maintenance and use of facilities and premises kept people safe. The imaging service ensured that non-ionising and ionising radiation had arrangements to control the area and restrict access.

Equipment was maintained and serviced in line with manufacturer guidance or whenever issues arose. Resuscitation equipment was readily available for both adults and children and staff checked it regularly.

Staff and carers used personal protective equipment when needed. Lead aprons and lead screens were checked annually for their integrity.

The provider had an equipment quality assurance programme and were carrying this out on all x-ray equipment and (and ultrasound and MRI equipment) at the appropriate time as recommended by the medical physics experts, manufacturers recommendations and in line with best practice guidance.

The service held an asset register which showed the ages of equipment and helped senior staff and managers plan in capital replacement projects. Backup systems supported ongoing essential service if there was a failure.

Arrangements for managing waste and clinical specimens kept people safe.

The imaging service undertook risk assessments for all new or modified uses of radiation, which took account of occupational safety as well as considering risks to people who used services. All assessments we reviewed were in date of review.

IT systems helped managers monitor demand and capacity of the service for future planning. For example, a new, easier requesting system had been introduced to GPs which had seen a spike in ultrasound referrals into the service. Extra funding had been agreed with local commissioners to recruit short term agency staff to support demand.

The provider undertook assessments and reviews of their activities under the Control of Substances Hazardous to Health Regulations 2002 (COSHH). However, in both CT scanners we saw chlorine cleaning tablets stored in unlocked cupboards. We escalated this and staff immediately removed and secured the items.

The service monitored staff for radiation exposure. However, staff told us they had never seen any dose reports but also explained if there was an increased dose on any report, senior staff would discuss it with them.

The service made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

Not all staff were not up to date with essential resuscitation training. Not all staff received effective training in safety systems, processes and practices. Data submitted for the whole trust showed the department had fallen short of trust targets in several areas including Level 2 adult resuscitation (54.8%) and Level 2 paediatric resuscitation (51.7%). and basic waste management (89.1%). However, there was now a trainer based at the Nightingale who was planning to start dedicated onsite face to face resuscitation training.

Not all staff had regular appraisals and one to one conversations. Data submitted showed only 35.7% of staff had received an appraisal at the time of our inspection across the diagnostic imaging department, across whole trust.

Staffing levels and skill mix were planned and reviewed so that people always received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix compared well with the planned levels and cover was provided for staff absence.

Arrangements for handovers and shift changes ensured that people were safe and allowed time for staff to plan, complete equipment checks and obtain any additional information required to perform safe scans, such as blood test results.

There were enough radiologists and radiographers to meet the demands of the service. Radiologists were available to provide advice each day. Radiographers from a third-party agency consistently worked at the service and had received inductions and training

The service used teleradiology services to meet reporting demands. As part of third-party contracts with these services, each company had to fill out declarations that they and their employees were complaint with all Royal College of Radiologist (RCR) standards required to report x-ray images.

Services ensured relevant staff continued registration with relevant bodies and gave support with revalidation where necessary.

Staff who were undergoing training, such as student radiographers, were adequately supervised in accordance with legislation set out under IR(ME)R.

Engineering support was supplied by formal maintenance contracts and by in-house engineers, which meant in house staff could perform some maintenance of the scanners and respond promptly in the event of equipment failure.

Staff received training to make them aware of the potential needs of people with mental health, learning disability, autism or dementia needs. Training records showed training compliance was 98.3%.

Radiographers and other healthcare professionals were able to train for additional tasks, such as reporting and line insertions.

The service had an established programme to train apprentice radiographers and had between 2- 3 people in each cohort of the programme.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff took precautions when seeing people with suspected communicable diseases. In the event of a patient attending with an infectious disease, staff had access to onsite cleaning staff and materials. If a patient was vulnerable to infection, patients were booked towards ends of lists to minimise contact with other patients.

The service maintained high standards of cleanliness and hygiene through comprehensive infection training and staff awareness. The service had reliable systems to prevent and protect people from a healthcare-associated infection. Staff had access to personal protective equipment (PPE) should they require it. Audits showed good staff compliance with hygiene processes including hand hygiene and logs of cleaning had no omissions.

The service had cleaning procedures for ultrasound probes using a recognised 2 step cleaning system.

Staff were provided with clean uniform and were familiar with the hospital uniform policy around covering uniform when travelling to and from work. Staff had access to showers and onsite changing facilities.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff were not always following hospital policies for medicine administration. In CT, we saw staff drew up multiple syringes of contrast in preparation for a list of contrast scans. This was not in line with hospital policy and had not been risk assessed and there was no standard operating procedure to ensure all staff were following the same process. We escalated this at the time of our assessment and the practice was immediately stopped. This meant there was a risk that the batch number of contrast would not be recorded against the correct patient. In the event of an allergic reaction this would mean the contrast batch used could not be traced.

However, medicines were ordered, transported, stored and disposed of safely and securely, including contrast agents and oxygen cylinders

Staff carried out comprehensive allergy and safety checks before all scans including those involving contrast medium. This information was stored on the radiology computer system and a warning flag alerted staff to previous allergies.

Staff used Patient Specific Directions for each scan which involved IV contrast. We saw radiologists recorded on the electronic system, the type, strength, amount and flow rate of contrast required for each scan.

Saline was used in prefilled syringes and did not require a Patient Group Direction (PGD). However, in MRI, a number of medicines were used in some cardiac scans, such as adenosine. The service used a dedicated MRI prescription form which was signed by the radiologist prior to the scan.

Contrast media and other medicines were stored correctly and in line with manufacturer guidance.