Nuffield Health Bristol Hospital - The Chesterfield

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• 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 the combined outpatients and diagnostic imaging key question of safe as good. At this assessment we have rated safe for diagnostic imaging as good. This meant people received safe care and treatment. However, recruitment records were not always complete. There was some printed safety information that was not up to date. Store areas were not always kept secure. There were some consumable items that were out of date. There were some items stored on the floor.

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 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 safety events. Lessons were learnt to continually identify and embed good practice.

The service had a current incident policy, to support systems to report, investigate and learn when things went wrong. Managers told us they encouraged staff to report all incidents as these enabled them to prevent reoccurrence. They said reports of incidents were used to improve safety for everyone, rather than apportioning blame to individuals.

We saw evidence of incidents having been investigated, and action taken to reduce the risk of recurrence. We looked at the system for managing incidents which was electronic. In the 12 months prior to our assessment there were 54 incidents, including near misses, reported. All incidents were reported as low or no harm to people. There was evidence that the service took action to prevent incidents reoccurring.

There had been no reported incidents requiring reporting under Ionising Radiation (Medical Exposure Regulations (IR(ME)R). Providers must report incidents where a patient receives a much greater dose of radiation than expected.

There had been no reported Never Events in the 12 months prior to our assessment. Never Events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. Staff told us what they would report as an incident which included the reporting of near misses.

Staff understood the duty of candour. They understood the importance of being open and transparent with patients and families when things went wrong. Staff received feedback from the investigation of incidents.

The service shared information and learning from incidents. Service leads and senior leaders in the hospital met weekly to review adverse events. This provided an opportunity to review learning and discuss actions. They also reviewed incidents to consider if they were required to be reported to external organisations and regulators. Staff in the service told us they had monthly meetings where they were made aware of incidents and any learning.

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.

There was an admission criterion for both private and NHS patients. These criteria set out who could be seen safely at the service.

There were systems and processes to ensure the correct patients were treated throughout the patient journey, and they only received the procedure which was intended.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. The service used The Society of Radiographers “Pause and Check” system. Pause and check consisted of the 3-point check to correctly identify the patient, as well as checking with the patient the site to be imaged, the existence of previous imaging and for the operator to ensure the correct imaging modality was used. We observed staff always using the 3-point demographic checks in line with the correct procedure.

All patients and visitors were required to complete MRI safety questionnaires. The safety questionnaires included asking patients if they had cardiac defibrillators or other devices in their chest, and patients were asked if they were pregnant. We saw these were completed. Gowns were available for patients to change into if their clothing contained metal, such as metal zips. All referrals included patient identification, contact details, clinical history, the examination requested, and details of the scan referrer.

The IT connectivity was consistently available across the service to meet the needs of staff completing the records. During our assessment, the service had an IT system failure. Staff followed processes to keep people and information safe during this system failure. The incident was discussed at the hospital meeting, where actions were discussed.

The service used reporting radiologists who worked remotely. There were processes to ensure they were using equipment that met required standards for reporting.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer. All patients we spoke with understood how they would receive results.

The evidence showed some shortfalls. Staff were not all trained to the correct level of safeguarding. However, 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.

Provider policies covering safeguarding training requirements were not aligned. The safeguarding policy stated all non-clinical staff, who have contact with children no matter how frequently, must be trained to level 2 for safeguarding children and young people. However, the mandatory training policy stated health care assistants and support workers should be trained to level 1. We were told this was an administrative error where staff were not allocated the correct level of training to complete.

In the 12 months prior to our assessment, there had been no safeguarding concerns raised to the local authority. Managers were confident that staff could identify safeguarding concerns. They said they also considered safeguarding when an incident occurred or complaints raised.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff understood specific safeguarding issues such as female genital mutilation and explained what actions they would take.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 2 for safeguarding adults. Records showed all staff had completed this training. Staff were trained to level 2 for safeguarding children and young people. Records showed 82% of staff completed the training. For more information on safeguarding children and young people, please see the services for children and young people’s assessment.

Staff received training to support people with individual needs. They received training in learning disabilities and autism. Records showed 84% of staff had completed this training. Outstanding training was scheduled for completion.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff. Staff could access a level 4 trained person within the provider’s wider organisation.

The service had an up-to-date chaperone policy, which all patients were informed of when they attended the service. There were chaperone posters in the department. Records showed that staff noted when a chaperone was used.

The service carried out checks with the Disclosure and Barring Service (DBS) for both adults and children barred lists.

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.

The service had processes to deal with emergences at the hospital and the mobile MRI unit. The service carried out emergency evacuation simulations for the MRI unit. This was to safely extract a patient. The service identified strengths and recommendations from the simulation and implemented changes to improve the process. Staff involved in the simulation told us this experience was good learning for them, and they were involved in making improvements.

The service worked with patients to understand and manage risks. The treatment and care met patients' needs in a way which was safe and supportive.

Staff communicated with patients so that they understood their care and treatment. We observed staff providing an explanation of an MRI procedure and confirmed that they understood the patients understanding of what was happening. Patients told us they were well informed.

The service had pregnancy status forms for all patients to complete aged 12 to 55 regardless of their gender. This was to prevent accidental radiation of exposure for all patients capable of being pregnant.

We spoke to 14 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

The service had equipment to support care for people having a medical emergency. The resuscitation trolley was checked daily. Paediatric and adult resuscitation policies were available as well as resuscitation council guidance. Staff received training in life support.

The service had a deteriorating patient policy which clearly set out roles and responsibilities for the health care team. It was clear in an emergency the patient should be transferred to the local NHS trust.

Patients could summon assistance and help as needed through the use of call bells and we saw patients were shown this. There were emergency alarm cords in rooms for patients to use. However, in 1 room the emergency cord was not all the way to the ground which meant people may not be able to active the alarm if they were on the floor. Staff corrected this during our assessment.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care.

Chemicals or substances hazardous to health (COSHH) were not always stored safely and information about products was not always up to date. During our assessment, we observed the sluice room was left unsecure, which meant some COSHH was accessible to unauthorised people. Printed COSHH files were not always up to date. The printed index of COSHH used in the service had 11 items listed and was valid until July 2024, whereas the index at the time of our assessment had 13 items listed and was valid until January 2027. Where printed documents are not controlled there is a risk these contain out of date information.

Single use items were not always within their use by date. During our inspection, we found 7 items in a store area that were past the use by date. These items used past this date may not have been as effective as designed when used. During our inspection staff removed these items from the service.

The service labelled equipment in the MRI area to identify if equipment was safe to use near a magnetic field. During the inspection we found 1 of 2 fire extinguishers in the MRI area was missing this label. However, the fire extinguisher was marked as being non-magnetic, and the MRI area at the hospital was not accessible for patients. After our onsite assessment, the service ordered new labels.

The service had the required warning signs for restricted areas. Rooms where X-ray imaging was carried out had required signage warning of the risk of ionising radiation exposure should a person enter the room un-authorised. The mobile MRI unit had warnings relating to magnetic field risks. During our assessment, the MRI scanner at the hospital was being replaced. Contractors had cordoned off the area and there was specific signage relating to the work being carried out.

There were information posters displayed in the service to inform patients of radiation risks and the effects on the human body.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment. They carried out quality assurance processes to ensure equipment was functioning as expected. Equipment was serviced by third party contracts. Results from these safety checks showed equipment was functioning as expected.

The service had policies and procedures to keep people safe. There were up to date local rules which reflected best practise. Local rules were available to staff, and were displayed on the mobile x-ray scanner.

The environment used for patient care reduced the risk of patient harm. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair or replacement of broken or missing equipment. Staff said they had access to spare equipment from other departments if necessary.

Staff had access to, and wore, personal protective equipment to keep them and others safe. The service had a process to visually check and test the effectiveness of lead aprons. The service monitored staff exposure to radiation.

The evidence showed some shortfalls. The service did not have complete recruitment checks. However, the service made sure there were enough staff who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The hospital did not have complete recruitment records for all staff. The provider is required under the Health and Social Care Act to complete and retain specific recruitment information to ensure staff are fit and proper to perform their roles. During our assessment, 3 out of the 8 files we reviewed had missing information. This included 1 file missing references, and 2 files were missing full reasonable adjustment checks.

We also checked practicing privileges which grant authority for a medical professional to practice at a specific location. We found 3 of 6 records had information missing. This included 1 file missing safeguarding training information, a different file was missing up to date appraisal information, and another file was missing reference checks.

The service deployed radiologists, radiographers, radiology assistants, and administration staff. The service used a mixture of permanent staff supported by bank staff.

Managers had tools to plan staffing levels depending on actual or planned activity. Staffing was planned in advance to cover each imaging modality and to maintain safe staffing levels in MRI where 2 staff members needed to be scheduled. Records showed staff were scheduled to modalities which they were suitably trained to perform.

Staff had a full induction when they started work. This included orientation of the service, responsibilities within the department, and competencies to use specific equipment. Staff we spoke with said they had an induction to the service.

The service had access at all hours to medical advice if needed. Where contrast was used in MRI imaging, a doctor was scheduled to attend in case a patient had a reaction to the contrast. Outside of the service's normal hours there was an on-call rota to meet the needs for imaging within the hospital. On-call staff were planned in advance.

The service had processes to monitor and manage staff absences. In the 12 months prior to our assessment, the service had an absence rate of 9.5% for radiographers, 15% for radiology assistants, and 28% for administration staff. Managers knew the reasons for absences and used the providers policies to manage and support staff absence. At the time of our assessment the service had 1 open vacancy.

Managers supported staff through constructive and recorded annual appraisals of their work and regular clinical supervision. At the time of our assessment most staff had received appraisals. Some appraisals had not been completed due to staff absence. All radiologists were required to provide evidence of appraisal and re-validation.

There were processes to deal with poor performance. Managers knew their responsibilities in managing performance and had support from the provider when required.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings.

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. However, there were some items stored on the floor.

The service had processes to clean and decontaminate equipment. The service had a high-level disinfection system for ultrasound probes that allowed highly effective decontamination and traceability. Traceability is the documented record linking the specific probe to the decontamination history and the patient it was used on.

The service was visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. During our assessment we saw staff clean equipment after patient contact. During our assessment, patients told us they found the service clean and tidy. Feedback gathered by the provider also showed this. A patient said, “I love the hospital. It was very bright and spotlessly clean.”

The service managed infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. During our assessment we saw that equipment was visibly clean.

There was an up-to-date provider infection, prevention, and control (IPC) policy and supporting guidance that was accessible to staff. Staff were able to access this policy on the providers IT system.

The service monitored and reviewed standards of IPC. There was a programme of IPC audits, including hand hygiene, IPC precautions, aseptic non-touch technique and environmental audits. Records showed the service was performing well achieving a score of at least 94%.

Staff supported IPC measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

We saw staff following infection control principles including compliant handwashing and the use of personal protective equipment (PPE).

Staff understood the process for managing spillage of body fluids in the department. There were spill kits available for use.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the provider’s policy. Sharps bins were managed safely. The mobile MRI unit had a separate clinical waste storage area which was secure.

Staff completed training in IPC and management of sharps. Records showed most staff had completed this training. Outstanding training was planned in for completion.

The provider participated in Patient-Led Assessment of the Care Environment (PLACE), which is a review of the care environment from patients and staff. In 2025 the hospital scored higher than the national and provider average for cleanliness.

Items were not always stored correctly. During our assessment, we saw some items were stored directly on the floor in storerooms. This made cleaning less effective and could lead to the contamination of the items stored on the floor. Staff removed these items during our assessment.

The evidence showed a good standard. 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 had access to the medicines required during planned diagnostic procedures, and pharmacy supported this ongoing supply.

Emergency medicines were available if needed, and staff knew how to access these.

The service had a system of audits to manage the safe use of medicines. Records showed improvements were made using audits. The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts.