Sulis Bath Hospital Limited Also known as Circle Bath

On this page

• 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 people 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 good. At this assessment the rating has changed to requires improvement. There were significant lapses in processes and procedures, leading to shortfalls in service that could impact on quality of care.

The service was in breach of legal regulation in relation to the governance of the service. We have asked the provider for an action plan in response to the concerns found at this assessment.

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 clear shared vision, strategy and culture developed in collaboration with key stakeholders. The service engaged with external stakeholders to gain an exceptional understanding of local needs and challenges. This was transformed into a set of defined objectives, where values underpinned service and staff development.

Leaders took a systematic approach to regularly measure progress against the services’ strategy. This examined how each department was performing against defined objectives, celebrated success and raised any limitations or support requirements that acted as a barrier. Staff understood how their team contributed to the overall direction of the hospital.

The service had inclusive leaders at all levels 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. Staff felt the leadership team were highly approachable and always demonstrated commitment to ensuring safety for patients and staff. They described leaders as trustworthy, transparent and supportive. However, some staff reported that leaders were not always visible and had had little, to no recent interaction, which made it difficult to build trust.

The service had a formal succession planning strategy covering staff development from healthcare support workers to department leads. There were several development pathways offered to staff across the service. This included Trainee Nursing Associate programmes, Registered Nurse Degree Apprenticeships and leadership training for all leads and deputies. The recruitment process reflected a values-based approach, to ensure staff and leaders were the correct fit. Internationally recruited staff reported being well supported and listened to.

Leaders fostered a positive culture where people felt they could speak up and their voice would be heard. Additional to the standard systems for speaking up about concerns, the service had a Freedom to Speak Up (FTSU) process. This was a process for escalating and raising concerns outside of the usual line management route, with multiple touchpoints within the organisation and externally. Staff we spoke with, knew who their local Freedom to Speak up Representatives were, and most staff felt able to raise concerns through this route.

Over half of respondents to the CQC issued staff survey did not know about the services’ whistleblowing policy or felt it had not been communicated effectively. Some staff lacked confidence in this process, citing that concerns were ignored or selectively actioned. However, review of the service's most recent annual Freedom to Speak Up report showed that leaders had addressed all 7 concerns raised and actions were taken in each instance. There were also anonymous staff feedback boxes available for those uncomfortable with engaging in the FTSU route.

The service did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders did not have oversight of workforce race and disability equality metrics, which is a requirement of the National Health Service standard contract. This meant the service was unable to effectively measure equality, diversity and inclusion impacts when managing their processes and procedures.

The policies we reviewed had no indicators for how leaders would ensure equality impact tools were used effectively. This means that equality impact might not be meaningfully assessed or inclusive as the service had no requirement for consultation with affected groups against the services' demographic information. Leaders might therefore be unaware of disparities in the experience of staff with protected characteristics, or from excluded and marginalised groups.

However, the service monitored gender pay gap inequalities. Leaders were aware of the increase to the gender pay gap and had indicated their commitment to close this by reducing barriers to female employees.

The service did not manage risk effectively despite clear systems and structures for good governance. Leaders did not always take effective action using the best information about risk, performance and outcomes.

The service had a governance structure which enabled committees addressing specific areas of oversight to feed into and inform the leadership team. However, it was not always effective. The service reported 2 Never Events in 2024, where foreign objects had been left inside patients after surgery. Never events are serious incidents that are preventable and should never happen. Leaders had carried out a patient safety incident investigation to identify if there were any shortcomings in practice. The updating of guidance for how, when and what items were accounted for during surgery, was discussed during the clinical governance meeting in December 2024.The guidance had been created in April 2024 following the first Never Event and leaders reviewed this following the second incident. The initial incident review and clinical governance meeting minutes showed the service had not effectively reviewed this incident and existing practices against best practice guidelines and standards. Investigation reports showed leaders had not fully reviewed the incident and existing processes against the sequential standards set by the National Safety Standards for Invasive Procedures 2 (NatSSIPs) 2. An informal record showed that staff had considered the overview of the sequential steps, but this was not detailed or complete. Additionally, the investigation report showed that the World Health Organisation safety checklist had been reviewed, but this covered only 3 of the 8 sequential steps. NatSSIPs 2 was not referenced in the investigation reports or policies shared. These documents also demonstrated that committee members had failed to provide effective challenge. This meant the service could not assure themselves that their processes met expected standards of care.

Also, some policies related to clinical assessment tools, for example sepsis, staffing and appraisals had not been updated for several years. The service had been using an outdated version of a safe nursing tool to assess acuity and dependency, to ensure nursing establishments reflected patient need. This meant the service might not be accurately assessing whether wards were staffed with the correct number of nurses. Leaders were aware of this and had begun to update the policy in 2023, to integrate the newest version of the tool. However, this had not been approved yet. Leaders mitigated this risk by using audits measuring safe staffing levels against the newest version of the tool three times a year. This was used to support decision making on safe staffing levels.

The hospital risk register reflected most of the current risks identified by leaders and had been reviewed monthly. However, the risk that the service did not have enough staff trained to an advanced level in safeguarding, had not been recorded to the register. The risk of patient harm due to increased levels of medicines prescribing and administration errors, had also not been recorded to the register. This showed a gap in governance procedures where shortfalls had not been recognised as patient safety risks. However, leaders raised this concern at committees and escalated to the executive team in January 2025, following the inspection. The service demonstrated the prescribing action plan was monitored monthly and identified no prescribing incidents which resulted in patient harm. Following the inspection, the service recognised the safeguarding risk and the lack of electronic prescribing system. This was recorded to the risk register.

However, the service had identified areas of improvement and development based on external audit recommendations. This led to the establishment of new safety committees like water safety and ventilation, to ensure compliance to health and safety standards. Some representatives were not always present for clinical governance meetings in 2024. This could impact on how responsive the service was to implementing change. For example, the service’s clinical governance action log had 11 actions that were overdue. The most overdue action was to update a cannula assessment tool, which was identified as a concern in February 2023. The service had planned to complete this in February 2024, but this was still not completed.

The service was challenged by insufficient governance staffing which had been noted to impact on key project activity. The policy and guidance register showed that over half of the documents used by the service had not been reviewed for over 3 years. This meant staff did not have the most current clinical guidance available to guide decision-making against expected standards of care. Senior leaders were aware of the current and prospective challenges to successful delivery. However, the forecasted improvement plan and interim actions shared, provided poor assurance that significant improvement would be achieved. This had been recorded to the hospital risk register since February 2023 as a medium risk, but the strategy to update and review 10 documents per month was not realistic. The service did not specify a time frame for improvement or identify practical considerations other than recruiting to vacancies. In addition to this, there had been no additional staffing to the team responsible, to enable the service to deliver this task, since the transition in hospital ownership in 2021. Clinical governance meeting minutes for December 2024 indicated leaders did not review this risk in detail. The service was unlikely to close the gap on this key project for another 3 years, and the strategy did not take into consideration the policies and guidance that would lapse in this period.

Leaders described using effective systems to manage the actions, behaviours and performance of staff when this fell below the expected standard. They provided examples of when leaders took proportionate action when this occurred.

The service collaborated with external stakeholders in partnership, to ensure services worked seamlessly for people. Staff shared information and learning with partners resulting in improvement of services that matched the needs of the community.

Leaders engaged with stakeholders, including the local Integrated Care Board, to measure whether the service was delivering against the wider healthcare strategy. Staff regularly met with local partners to corroborate and standardise their processes and procedures. This recently led to integration of national transfusion service guidelines which could potentially reduce unnecessary blood testing and expenditure.

The service supported patient treatment transfer from 9 NHS Trusts across the region. This meant patients who had been on waiting lists for surgery for a long time, were able to have their surgery sooner than expected. Partnership working and collaboration had identified innovative ideas leading to better outcomes for people. This had generated improvement areas to standardise and improve theatre efficiency in line with best practice initiatives. Staff enhanced NHS capacity and efficiency by integrating a same day arthroplasty programme with the aim to improve patient outcomes. This reduced bed utilisation with average stay decreased from 2.84 to 1.15 days per patient.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff and leaders understood how to make improvements happen. Learning was shared when leaders identified areas of good practice and when things did not go as planned. The approach was consistent, measuring outcomes and impact on quality of life.

Leaders used systems to effectively identify potential clusters of repeat events. Relevant staff were consulted and involved in these reviews to support a multidisciplinary approach to learning and improvement. A rapid response investigation in May 2024 found errors being made during scheduling and booking which meant patients were booked for surgery on the wrong side. Leaders introduced several measures to manage this risk and monitored the effectiveness at planned intervals.

Staff shared an example of innovation, where leaders listened to and supported their ideas on improving the service’s environmental sustainability. Staff were supported to trial an extended recycling service and roll this out to all areas of the hospital. Leaders recognised and celebrated this proactive approach to improve the service.

The service requested further information for every piece of negative feedback submitted by patients. Action logs showed that staff addressed potential and actual shortfalls in patient experience and care, demonstrating a closed loop of learning. However, this did not include equality, diversity and inclusion monitoring.