Nuffield Health Bristol Hospital - The Chesterfield

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• 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 patients 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 the combined outpatients and diagnostic imaging key question of well-led as good. At this assessment we have rated well-led for diagnostic imaging as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. However, the service was in breach of legal regulations as the provider did not always have effective governance processes for recruitment of staff and some policies were not aligned.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider was a health and wellbeing charity who saw their purpose to improve the health and wellbeing of the nation. They aimed to help individuals achieve, maintain and recover to the level of health and wellbeing that they aspire to, by being a trusted provider and partner. This was underpinned by 5 ambitions and 4 values. Not all staff could identify these ambitions or values, but they understood what the service was trying to achieve and expectations the service had for service delivery.

The ambitions were built into the appraisal process. Managers told us they monitored complaints, incidents and audits to understand if the service was meeting their purpose.

The service had objectives and actions based on the provider’s ambitions. Actions to meet objectives were monitored and revised as necessary. For example, some actions were on hold as they related to significant capital investment into diagnostic equipment. Managers had plans to review related actions once equipment was operational.

The staff felt the provider’s vision and values fitted well with their views on care delivery. The staff survey from December 2025 showed most staff felt a strong organisation fit with a score of 8.2 out of 10. This score was in line with the hospital’s benchmark.

The evidence showed a good standard. 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. They did so with integrity, openness, and honesty.

The service had a registered manager with the CQC. A registered manager is a person who is legally responsible for the day-to-day care provided at a location. The registered manager understood their roles and responsibilities.

Leaders told us they wanted everyone at the hospital to act with civility (treating others with respect and working in harmony) and professionalism. They aimed to be open and accessible with all staff and operated an open door policy. Staff at the service told us senior leaders were visible and they felt able to raise issues.

Senior leaders told us they were passionate about developing staff capabilities within the provider. They were focused on giving staff development opportunities and each department had succession plans to develop new leaders. In the December 2025 staff survey, most staff said they could develop within the service.

The overall lead for the diagnostic imaging service was the radiology manager. They understood the service, how it operated and the role of imaging in improving people’s health and wellbeing.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The hospital had 2 Freedom to Speak Up Champions. One champion was clinical and the other is non-clinical. Staff told us champions took time to speak to the staff at the service during a staff meeting.

The service had a freedom to speak up policy which identified roles and responsibilities of staff and provided guidance on raising concerns. Managers were confident staff knew how to raise issues using the provider’s processes. They felt there was always a need to refresh staff’s knowledge around raising concerns.

In the 12 months prior to our assessment, 3 incidents were raised within the hospital using the freedom to speak up process. These were not identified as being specific to the service. Managers told us of an incident prior to this reporting period, where they took appropriate action relating to concerns raised.

The provider’s website detailed how people could raise a concern and how this would be investigated. There were complaint escalation routes for private and NHS funded care. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

Staff received training in freedom to speak up. Records showed all staff had completed the training module. They also received training in bullying and harassment. Records showed most staff had completed this training; outstanding training was planned for completion.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders reported using an anonymous recruitment process focused on applicants’ skills and qualifications, with personal identifiers such as names and ethnicity removed to help reduce bias. Leaders were mindful of panel selection and made sure there was diverse representation to support a fair and inclusive recruitment process.

The provider had colleague networks for specific groups of people. The purpose of these networks was for staff to share their experiences and make improvements to the workplace.

The service had an up-to-date equality, diversity and in inclusion policy. We observed leaders being approachable and supportive to all members of staff.

The service made reasonable adjustments for staff when required. Managers told us of an example of a reasonable adjustment for members of staff. Staff were supported with changes to work patterns, and support from occupational health.

The evidence showed some shortfalls in standard. The hospital did not always operate governance process to identify and mitigate risk. However, the service had clear responsibilities, roles, and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The hospital did not always have effective governance processes. Governance processes did not always identify gaps in recruitment records and practice privileges that we found during our assessment.

Processes did not identify 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. Records showed healthcare assistants and support workers were only trained to level 1.

The hospital had systems and processes to manage other aspects of safety and quality of care. These processes included a variety of committees and groups to ensure specialist oversight of specific areas of risk and performance. There was a radiation protection committee which held annual meetings to oversee the safe use of ionising radiation and monitor compliance against regulations. Records showed these meetings were well attended by key people, and radiation safety and performance was discussed.

The governance system monitored the safety of services. There were regular meetings involving key service managers, which provided them with oversight of risk at both a departmental and hospital level. High level department risks were escalated and monitored on the hospital risk register. Governance arrangements worked effectively. However, the processes had not identified all risks that are noted in areas of this assessment report.

The hospital had access to capital funding to replace equipment and was able to replace items found to be risks on the risk registers. At the time of our assessment the provider was making a significant investment in new diagnostic imaging equipment. Managers said processes used to monitor equipment performance enabled a business case for new equipment to be authorised.

Where improvements were required, managers ensured action plans and the monitoring of these led to changes. The audit process covered areas such as infection prevention control and radiation protection.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities.

Leaders made sure that accurate information was discussed and shared with key staff. Staff felt well informed on key issues and performance.

The hospital had systems to manage risks. For example, there were processes to test emergency generators should power supply be affected. Tests on water safety were carried out. Where there were issues identified, actions were taken to manage risk.

The service had a business continuity plan which would be put into operation in the event of an unexpected disruption to the service. This included a short-term disruption plan. Should the hospital need to be evacuated there were printed up-to-date business continuity plans and information.

The provider had a sustainability plan with a target for each hospital to reduce energy consumption. Managers of the service were aware of this plan and were working on implementing energy reduction plans without impacting patient care.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The hospital ran free of charge events where the public could attend presentations on a variety of health topics. This could be booked on the provider’s website.

The hospital worked with the wider provider group to support charitable and social partnerships. They held free continued professional education sessions for health care professionals not employed by the provider. They also engaged with the wider community such as educating school children on hand hygiene.

The hospital worked with others to review service provision. Leaders told us they had a monthly meeting with other local hospitals and local NHS trusts to discuss concerns and share information across the area. These meetings were not recorded.

People who used the service felt care and treatment was well co-ordinated, and staff engaged with them to keep them informed about their scan procedure and the reporting of scan results.

The service focused on improvement across the organisation. Staff actively contribute to safe, effective practice.

The hospital worked with the provider’s wider diagnostic imaging service. For example, during our assessment we observed the service participate in a radiation protection supervisors forum meeting. The meeting had a set agenda where new procedures, improvements and innovation were discussed.

Shortly prior to our assessment, they introduced same-day imaging for post-surgery patients. Initial feedback from colleagues in the service was positive and resulted in faster discharges.

The service reviewed and invested in equipment to improve service delivery. For example, at the time of our assessment they were completing the installation of a new MRI scanner.

The service had plans to expand imaging provision. There were business cases for areas of expansion to meet future demands.