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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that 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.

This is the first inspection for this service and this key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. Staff listened to concerns about safety and investigated and reported safety events.

Following our on-site assessment, the trust sent us information about 3 incidents which took place in surgery in the last 12 months at the Nightingale Hospital Exeter. These had been initially reviewed but did not meet their criteria for patient safety incident investigation (PSII). PSII’s were undertaken in line with the criteria in the trust’s Patient Safety Incident Response Plan. This would be an event which met a national priority for PSII and was 1 of the trust’s local patient safety priorities. One of these incidents was a never event, however when the trust reviewed it, they decided it did not meet the criteria for a never event. Following our site visit, this incident was re-reviewed by the trust and other stakeholders and was then deemed a never event. However, this incident was investigated, and an action plan devised to prevent the same thing from happening again. A "never event" is a serious, largely preventable patient safety incident that should not occur if relevant preventative measures have been put in place.

Staff understood their duty to raise concerns, record safety incidents and near misses, and report them both internally and externally. They followed trust-issued guidance for incident reporting, which included grading and potential investigation. Senior staff promoted a culture of openness with staff by encouraging suggestions to improve patient care. For instance, a team member proposed changes to post-surgery pain relief, which was implemented and led to improved patient recovery.

Staff told us learning from incidents at other locations managed by the trust was shared with them. We saw in the incident reports how learning was shared with staff. For example, face to face meetings, posters and updating of guidance used by staff to reflect changes to practice.

Staff were aware of the Duty of Candour (DoC) legislation, which requires healthcare providers to be open and honest with patients when care or treatment goes wrong. Incident reports from the on-site assessment indicated DoC was considered, but this was communicated verbally and noted in patient records.

The Mortality and Morbidity (M&M) process for the Surgery Care Group aimed to review patient outcomes and improve care quality through systematic evaluation of deaths and complications. Surgical consultants participated in speciality-based meetings across the trust, scheduled according to the volume of data. Records showed that these meetings identified learning from adverse outcomes and developed actions to improve practice where needed.

The service worked with people 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 people moved between different services.

The service's referral and admission process ensured all necessary patient information was gathered to assess safety and suitability. The cataract surgery Standard Operating Procedure (SOP), under review at the time of our assessment, clearly outlined staff responsibilities. Patients referred for fast-track bilateral cataract surgery were screened via consultant-led phone calls to confirm eligibility and discuss risks. Suitable patients were invited for a `one-stop' assessment and surgery, followed by safe transfer to theatre after preoperative checks.

Patients undergoing orthopaedic surgery attended a pre assessment clinic. If staff had any concerns, they would refer the patient for assessment to an anaesthetist. Advice was given to patients about the surgery pathway.

We observed the discharge process and saw patients were provided with full instructions, both written and verbally along with an emergency contact telephone number, to follow post surgery. To ensure safe transition from hospital to home staff followed guidance as part of the pathway for patients. This included details about medicines and when to take them, when to re-start any medicines, how to manage any wounds and when patients needed to escalate any issues they might experience. Patients told us they had enough information about their care and treatment.

The Nightingale Hospital Exeter website had information for patients regarding the surgery they were planned to have. This included pre and post operation advice in words and videos.

Staff had access to an escalation procedure to follow if a patient required transfer to the acute hospital due to a deterioration in their medical condition.

Information was sent to the patients GP once they were discharged to maintain continuity of care.

The purpose of The Nightingale Hospital Exeter was to reduce waiting times for patients within the Devon area. The service was managed by Royal Devon University Healthcare NHS Foundation Trust. Patients from other NHS trusts in Devon were referred to them if they met the criteria for admission. When patients were seen from other trusts in Devon, they were still under the care of their referring trust which maintained continuity of care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 had access to the trust's safeguarding policy which aligned with local and national guidance. As part of a Devon-wide partnership, the trust used a shared policy to ensure patient safety. The policy outlined steps for reporting suspected abuse, and all referrals were made to the local authority. Staff reported confidence in making safeguarding referrals when needed.

A senior member of staff at the Nightingale Hospital Exeter was allocated as the safeguarding lead and staff were aware they could go to them if they required any advice or support. Clinical matrons were undertaking safeguarding level 3 training at the time of our site visit which is required for their role.

All staff were required to undertake safeguarding training. Mandatory training rates for this location for adults and children's safeguarding level 1 and 2 met the providers target and were over 90% compliant.

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 ensured patients understood their care and treatment, using tailored communication methods for those with communication difficulties. Patients were assessed for surgical suitability, guided by trust-provided criteria. Pre-assessment clinics specifically evaluated candidates for orthopaedic procedures.

Staff completed a preadmission assessment for patients attending orthopaedic surgery. Staff gave patients details on fasting, when to stop certain medications and for joint surgery advice about the pre operation drinks provided to help reduce the stress on the body and improve recovery.

The service used the nationally recognised World Health Organisation (WHO) 5 Steps to Safer Surgery checklist. This was a checklist developed to decrease errors and adverse events and improve safety and outcomes for patients undergoing surgical procedures. Staff told us audits of the WHO showed compliance with the process. After our site visit, we requested 3 months of audits to check on their compliance. However, there had been some issues with some of the audits, and they were not able to send these, therefore we could not check ongoing compliance. We reviewed 1 audit of the WHO 5 steps to Safer Surgery checklist and this showed there was good compliance amongst staff. Observations during our site visit showed staff usage of the WHO safety checklist was embedded into their practice, with staff fully interactive and focussed with the process.

Staff followed an escalation procedure for transferring patients to acute care when their condition deteriorated. They used the National Early Warning Score (NEWS2) to identify and respond to clinical changes, conducting vital observations throughout the surgical pathway. The service also had sepsis screening, aligned with the national Sepsis 6 Pathway. The Sepsis 6 Pathway is a set of 6 immediate actions designed to improve survival rates in patients with suspected sepsis.

Staff enabled patients to give feedback on the service they received. We saw feedback forms on display throughout the location.

Resuscitation equipment was located throughout all surgical areas. These were checked frequently by staff and were ready to use if required and easily accessible.

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

Staff proactively managed risks and ensured equipment, facilities, and technology supported safe care. Equipment was regularly serviced and ready for use. Advanced technology, including robotic systems in orthopaedic surgery, enhanced precision and visualisation resulting in smaller incisions, less pain, and quicker recovery for patients.

Staff had access to domestic and clinical waste bins and these were emptied regularly. Sharps and hazardous waste bins were stored safely. However, some products deemed hazardous to health were not securely stored in accordance with UK regulations designed to protect people from health risks associated with hazardous substances used at work. This was reported to senior staff during the visit and was addressed immediately.

To assist patients in finding their way around there was different coloured lines on the floor to follow depending on which service they were visiting. Patients told us they were able to navigate easily to the areas they needed to be.

The management team prioritised accessibility for all patients. Service leaders conducted an audit against accessibility standards where the premises performed well. The audit identified some areas for improvement and they began implementing recommended improvements, such as installing a bariatric toilet and enhancing external wheelchair ramps in response.

However, there was no onsite car park for patients and their relatives/carers at the Nightingale Hospital Exeter. There were only drop off areas if arriving by car or taxi. A free shuttle bus operated from the local park and ride areas which was free to park. Public transport services were also available. Only 1 patient we spoke with during the inspection felt this was an issue as they had to get 2 buses to get to the location. The service was aware parking for patients was a problem and was looking at ways to improve the car parking facility at this location. The trust told us following the site visit, the location site access plan included all elements of patient access due to geographical limitations.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs.

Staffing was reviewed at the start of each shift and adjusted as needed. Issues were escalated via trust procedures, with clinical matrons attending staffing meetings to raise concerns. Theatre coordinators assessed whether lists could proceed safely. No theatre lists were cancelled in the past 3 months due to staffing shortages, and staff reported adequate coverage to meet patient needs.

Consultants from different NHS trusts worked under a service level agreement within the surgery department for orthopaedics and ophthalmology. They completed an induction before working at the Nightingale Hospital Exeter to ensure they understood the service.

There was limited use of bank and agency staff in both orthopaedics and ophthalmology. When bank/agency were used they were block booked to maintain continuity of the service.

The turnover rate for orthopaedic staff was below the trust target. For ophthalmology, the turnover rate was above the trust target. Senior staff told us, and the data confirmed due to ophthalmology having a small team this made the turnover figure higher than the trust average. The turnover rate across all staff groups for the trust, was consistently below the national average up to January 2025.

The overall sickness rate for orthopaedics staff was above the trust target and for ophthalmology staff it was just below the trust target. All reasons for staff sickness were recorded. Staff sickness across all staff groups for the trust, was consistently in line with the national average up to January 2025.

Most staff had received an appraisal. The appraisal compliance rate for orthopaedics staff and ophthalmology staff was above the trust average and target rate.

Staff were up to date with their mandatory training requirements.

We reviewed recruitment files for employees and found the service was compliant with the necessary regulatory requirements. Staff had the necessary checks before commencing employment with the service to ensure they were suitable to support patients.

Volunteers had pre-employment checks and received appropriate training. The site had 17 active volunteers at the time of the assessment. Feedback on volunteers was positive.

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 maintained equipment well and kept it clean. We observed `clean' stickers were visible and in date to indicate when equipment had last been cleaned. Staff had access to guidance on how to decontaminate equipment. All equipment used in theatres was single use or sent off site to a designated sterile services department for decontamination and cleaning.

All ward areas and theatres were visibly clean, had suitable furnishings which could be easily cleaned and were well-maintained. The cleaning of the communal areas was by an external provider and patients commented on how very clean everything was.

Cleaning records were up to date and demonstrated ward and theatres were cleaned regularly. Staff also completed hand hygiene audits and bare below the elbow audits. These demonstrated a good level of staff compliance. Results and any actions following the audits were fed back to staff to ensure they were aware of good practice identified and any improvements needed.

Staff adhered to infection control principles, including handwashing, bare below the elbows and they had access to hand gel around each department. Staff had access to the trust's policies and procedures for infection control. Staff were up to date with their infection prevention and control training.

Surgical site infection rates were monitored by senior staff. For example, this trust was 1 of the 2 trusts identified in November 2024 by the UK Health Security Agency (UKHSA) as low outliers for total hip replacement surgery in their annual report published in December 2024. The trust continued to have very low rates of infection in the hip category. For knee surgery, the trust reported 1 infection from January 2024 to December 2024. This was investigated and deemed unavoidable.

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

Staff followed good practice in medicines management, and this included dispensing of medicines, administration, recording and disposal. However, not all medicines were stored securely. For example, during our visit we found 1 of the medication rooms was not locked which meant it could be accessed by unauthorised persons. This was reported to senior staff and was addressed during our site visit. Following the inspection feedback from the trust said the lock of this room had been identified the day before our site visit. Whilst it was unlocked a member of staff was positioned outside to prevent unauthorised access. The room did not have any controlled medicines stored in there which minimised any potential risks to patient safety”

Controlled medicines were stored securely and staff checked them daily for safety and compliance with the records.

Qualified staff administered medicines for patients to take home following the pathway based on surgery they had performed. Patients were given a medication administration record which contained details of, for example, when medication needed to be taken and for how long.

Medical gases were stored securely. However, 1 medicine rooms did not have a thermometer to check it was at a safe temperature to store medicines. The temperature of fridges for the storage of medicines which required refrigeration were monitored daily and within safe limits. Following the inspection the trust told us the 1 room we identified had temperatures checked using the digital temperature control and were found to within expected tolerances.

Patients at their pre assessment appointment were given advice on when to stop certain medicines before their surgery.