North Bristol Private 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 people were protected from abuse and avoidable harm.

This was the first inspection for this service which was registered in 2023. At this inspection we rated safe as good. Patient areas were safe, clean, well equipped and furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse. The service used systems and processes to safely prescribe, administer and record medicines. The service managed patient safety incidents well and infection prevention and control measures helped to provide a safe environment for patients.

However, we found laundry and food preparation were taking place in the same area. This is contrary to Health Technical Memorandum 01.04 which states linen should not be processed in kitchen areas to prevent cross-contamination and the build up of dust. Since the inspection we have received evidence the provider has moved the laundry equipment to a separate area.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service a 3. The evidence showed a good standard. 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.

Staff were confident to report incidents and knew what to report and when. Staff had effective systems to raise concerns both formally and informally. There was an incident reporting policy. This was also available in the staff room, which gave information about what types of events constituted an incident and how to report an incident. The registered manager reviewed all incidents, and themes and trends were discussed at management meetings. We saw evidence of this in meeting minutes. There were 3 incidents reported during the last 6 month period preceding the inspection. We saw evidence that the incidents were shared with staff and staff received feedback from investigation of incidents. There were staff information boards installed in the staff room areas which were regularly updated to ensure staff remained informed about training opportunities, safety alerts and recent learning from incidents. The service submitted data to the Private Healthcare Information Network (“PHIN”). PHIN is an organization that supports patients in making informed healthcare choices. They provide information about quality, safety and costs for private healthcare in the UK. The last data from PHIN received was September 2025 where it was stated the hospital had reported no incidents.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care. There was a policy to help staff follow the duty of candour process to staff.

We scored the service as 3. The evidence showed a good standard. 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 the patient was received to determine if the patient’s needs could safely be met. The service had a policy which clearly set out patients it would accept and patients it would not accept based on clinical indicators.

Staff involved other healthcare services to ensure patients had continuity of safe care, both within the service and post-discharge. The service informed the patient’s General Practitioner about the surgical procedure and often requested information from the General Practitioner prior to surgery. Post discharge there were scheduled follow up appointments with the nurse and the consultant. A helpline was available outside of regular hours for patients to call if they had any concerns following surgery. One patient commented “After care has been thorough and any question or query dealt with quickly. I would definitely recommend.” Another patient commented “The aftercare is 10/10 and completely different to what I experienced in the past”.

The service used an organisation that provided adult critical care transfer services should a patient require transfer from the private hospital to the emergency department. Although this service had not been used to date, it was anticipated that it would ensure prompt transfer to the emergency department.

We scored the service a 3. The evidence showed a good standard. 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.

Safeguarding policies and procedures were easily accessible in both electronic and paper formats, and staff knew where to find them. Staff were trained in safeguarding, knew how to make a safeguarding alert when required. The medical director was the designated safeguarding lead and was trained to Level 3. All staff had received safeguarding for adults at least level 2.

Staff could give examples of taking psychological considerations into account when carrying out pre-assessment checks as well as looking to see if a person had been coerced into having surgery. We were told when staff had concerns, they sought assurance from the General Practitioner about whether the person was psychologically fit for surgery. We were also informed that patients were appropriately referred to counselling and or psychiatric support services if required.

We scored the service a 3. The evidence showed a good standard. 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 completed comprehensive pre-operative consultations and assessments for all patients in line with national guidance. Staff communicated with patients so that they understood their care and treatment. Feedback from patients using the service was positive. One patient said, ‘They made sure I knew everything that was going on and how everything worked, and I felt very confident that they were knowledgeable about my condition”.

The service was a private cosmetic surgery. People who were treated paid for the service. Managers told us patients who attended the clinic were generally very low risk and patients were risk assessed at the assessment appointment prior to the surgical procedure. All patients undergoing surgery were asked to wear compression stockings following surgery to minimise the risk of venous thromboembolism following a VTE assessment. A pneumatic compression device was also used during surgical procedures and in the recovery room. An intermittent pneumatic compression device is an inflatable sleeve that helps prevent blood clots by promoting blood circulation in the legs There was a Bair Hugger system, a forced-air warming device used in hospitals to prevent hypothermia during surgery. This was checked regularly.

During our inspection, we observed staff completing a World Health Organisation ("WHO") safety checklist and saw it was done thoroughly and was embedded into practice. The WHO surgical safety checklist is a process to ensure surgical teams perform critical safety checks before and after a surgical procedure.

Staff used the national early warning score (NEWS) tool to promptly identify deterioration in a patients’ condition. Staff completed clinical observations on patients during and following surgery. We saw these had all been recorded in the patients’ records however in 2 out of 5 files there were issues with staff totalling the overall NEWS score. The provider told us and we saw they regularly audited patient documentation and improvement actions were highlighted to staff. We saw there had been an improving trend in the NEWS audit results At the last audit in October 2025, where 10 patients documents were sampled, compliance was at 93%

We scored the service as 2. The evidence showed some shortfalls. The service made sure equipment, facilities and technology supported the delivery of safe care. The design of the clinic environment, including treatment rooms, operating theatres, en-suite patient rooms and the recovery room followed national guidance and all areas were well-maintained. However, we found laundry and food preparation was taking place in the same room which was not in line with recommended guidelines. We raised this with the provider at the time of the inspection. Following the inspection, the provide sent evidence to show that improvements had been made and that the laundry room had been moved to a new location as of the 22 October 2025. Immediately following our inspection the provider also took steps to move food preparation into a separate room until this permanent solution could be enacted.

Staff reported equipment defects to managers. The service had a system to ensure defected equipment was removed from use. Equipment was maintained by an external company. It was tested once a year or as and when required. There was a back-up generator in case of an electricity outage to ensure those undergoing a surgical procedure were kept safe.

The consulting rooms were clean and spacious. The privacy curtains were changed regularly at a period of every 3 months or as and when required. There were 3 ensuite rooms for patients, all of which had the necessary equipment such as oxygen points and call bells both in the room and in the bathroom.

The service employed an external contractor to carry out air quality testing, electrical systems maintenance, fire safety assessments, water checks and portable appliance testing. Daily water and fire safety checks were carried out by staff. The service had a fire plan and appointed fire wardens. There was a designated refuge area for disabled people to wait in the building in the event of a fire and an evacuation chair to use for people unable to walk.

Staff carried out daily safety checks of specialist equipment, including the resuscitation equipment.

We scored the service a 3. The evidence showed a good standard. 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 a core number of staff that were employed directly. At the time of the inspection this made up 7 staff. The service also had a pool of bank staff that were employed to work flexible hours and enabled the service to ensure there were safe staffing levels for surgery and patients who stayed overnight. At the time of the inspection, there were 6 scrub nurses, 4 Registered General Nurses and 1 Health Care Assistant. Consulting and anaesthetic staff worked at the service under practicing privileges. Practicing privileges are a well-established system of checks and agreements to enables doctors to practice in hospitals without being directly employed by them. We checked practicing privileges files and saw that all the required information had been obtained for doctors to enable them to work at the location safely.

Bank staff received an induction and were familiar with the service. There was an induction process which included a supernumerary period that had to be signed off by a manager to ensure that they were safe to work for the service.

When there was a patient staying overnight, the service ensured there was a resident medical doctor and a registered nurse working to ensure the safety of their patients.

All Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

Managers provided staff with supervision (meetings to discuss care management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. All staff had completed an appraisal at the time of the inspection. Bank staff also received regular one to one meetings and yearly appraisals based upon the number of shifts completed. There were 2 bank staff who had worked for the service over a year and they had both received an annual appraisal.

We reviewed 3 recruitment files for employees and found the service was mostly compliant with Schedule 3 of the Health and Social Care Act and staff had the necessary checks before commencing employment with the service. At the time of the inspection there was one employee that required a second reference however following the inspection we received notification this had been received.

We scored the service a 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All areas of the clinic, including reception areas, offices, storage rooms and patient treatment areas were clean and had suitable furnishings which were clean and well-maintained. Flooring throughout the clinic was well-maintained and visibly clean. The service was fully compliant with Health Building Note (HBN) 00-09 which provides essential guidelines for infection control in healthcare facilities.

The service followed national guidance for minimizing surgical site infections. Patients were offered clear advice and information on how to care for their wounds after discharge and were given advice about how to recognise a surgical site infection and a helpline to call 24/7 if they had any concerns. Surgical site infections were monitored by the provider to see if there were any themes or trends or any learning identified which would reduce the risk of surgical site infections.

We observed a purpose built theatre environment which was visibly clean and hygienic. The mechanical air ventilation system was built above the specification for theatres and conformed to the guidance in Health Building Notes for surgical procedures set by NHS England. This helped to ensure a sterile and controlled theatre environment. The theatre environment was regularly tested by the theatre manager for signs of infection. This was carried out by swabbing different items and areas within the theatre to ensure the area was clean and sterile. This was audited. The theatre air ventilation system was tested annually. A recent audit completed following the swabbing of theatres and minor ops showed cleaning methods were of a high and compliant standard.

The policy for the decontamination of equipment and medical devices showed there was consideration for the different levels of cleaning necessary to prevent the spread of infection. The company used an external company to ensure re-usable surgical equipment was sterilised by steam under pressure at 134 degrees Celsius for at least three minutes. This was in line with national guidance on decontamination of surgical instruments.

Cleaning records were up to date and demonstrated clinical areas were cleaned regularly.

Staff adhered to infection control principles, including hand washing. Hand hygiene audits were carried out which showed good adherence to hand hygiene protocols.

Hazardous and clinical waste was disposed of safely and responsibly managed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff followed good practice in medicines management in terms of dispensing, administration, reconciliation, recording and disposal of medicine, however we found storage of medicines was not always in line with the manufacturer’s guidelines.

At our inspection we found one room where medicines were stored which was outside of the ambient room temperature of 25 degrees Celsius which many of the medicine manufacturers did not recommend. On the day of inspection, the room was at 25.3 degrees Celsius. The service had carried out regular temperature checks of this room, however, this process was carried out first thing in the morning. We raised this issue with the provider who carried out a stock check of the medicine and disposed of any medicine which the high temperature may have affected. These medicines were then moved to the recovery room medicine area which was air conditioned until air conditioning could be fitted into the original room.

Staff reviewed each patient’s medicines prior to surgery as part of the safety brief and explained to patients what they would be given and any potential side effects. Anti-sickness medication, pain relief and antibiotics, when required, were prescribed to take home and we saw staff provided detailed advice about medicines before discharge. Patients who were using ‘diet drugs’ such as GLP-1 Agonists were advised to fast for longer periods of time prior to having surgery. The admission assessment asked whether patients were on any diet medication.

We reviewed a sample of medicines in the emergency trolley, theatre and in the ward medicine
cabinet. All were stored correctly and within expiry date. Controlled drugs were disposed of according to the Misuse of Drugs act 1971 and the Misuse of drugs regulations 2001 plus amendments. Medicine that had to be stored below room temperature was kept in fridges. Checks on the fridge temperatures ensured temperatures did not exceed the recommended range.

Staff followed systems and processes to prescribe and administer medicines safely. Only staff who
had completed competencies in the management of medicines dispensed and administered
medicines to patients. Staff prescribed, administered and recorded pain relief accurately. In the patients’ records we reviewed all documentation relating to the prescription and administration of pain relief was completed and signed appropriately.

Staff monitored patients for nausea and vomiting during and after their procedure and prior to discharge. Patients were prescribed anti-sickness medication to take home with them. This was reviewed during follow up calls and appointments.