Nuffield Health Bristol Hospital - The Chesterfield

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 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. However, governance processes did not always identify risks.

At our last assessment we rated this key question good. At this assessment the rating has remained 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. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. They told us they could raise concerns without fear of negative consequences.

A positive and supportive culture was evident among outpatient staff. Staff were motivated to provide a high-quality patient experience and deliver person-centred care.

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 had the skills, knowledge and experience to perform their roles. They understood the services well and explained clearly how teams worked to deliver high quality care. Leaders were proud of the teams and described them as being passionate and committed.

Leaders were described as visible and staff reported good relationships with senior leaders, who were approachable. Staff said managers were easy to contact and offered support when needed.

Staff felt that leaders listened to their concerns and took appropriate action to drive improvements within the service. Overall, staff reported feeling well supported by their management team. This was reflected in the staff survey results, where the category of management support scored 9.2 out of 10.

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.

Patients had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients received online surveys and questionnaires asking them about their experience. Responses were reviewed by each service and actions taken to drive improvement.

All staff had completed training in Freedom to Speak Up. The service had 2 Freedom to Speak Up Guardians on site and had access to a regional Freedom to Speak Up lead. Staff could attend drop in sessions or contact them directly to raise concerns. Staff said they could raise concerns openly and they were aware of Freedom to Speak Up arrangements and felt there were clear ways to escalate concerns if needed.

The provider’s website detailed how patients 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.

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.

All staff were required to complete equality and diversity training. Leaders took action to review and improve the organisation’s culture, with a focus on equality, diversity and inclusion.

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.

Leaders made reasonable adjustments for staff members, enabling them to work on site and carry out their roles effectively. Adjustments were tailored to individual needs and demonstrated a commitment to supporting staff wellbeing, inclusion, and equal access to employment opportunities.

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 practicing 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 service had a clear governance framework with defined meeting schedules and requirements. Leaders described and we saw evidence of clinical governance and hospital quality safety meetings. There were clear actions and accountability to take them forward.

Incidents and complaints were investigated and responded to appropriately. Staff told us they received feedback and learning from incidents however, this was not consistently embedded across all services. Some incidents recurred due to learning and process changes not being consistently implemented across services.

There was an up-to-date hospital and departmental risk register. Leaders were aware of key risks, had plans to mitigate them, and implemented measures to maintain staff and patient safety while longer-term solutions were progressed.

There was a medical advisory committee led by a chair and supported by the service leadership, who were responsible for approving practising privileges and reviewing clinical outcomes of individual doctors. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Staff could find policies and procedures on an online platform and review new documents when they were published. Leaders could review who had read the document to ensure compliance in their service. Leaders also cascaded relevant information in team meetings and highlighted important information for the team to read.

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.

Leaders worked with relevant stakeholders such as commissioners and local hospitals to improve care and treatment for patients using the service. There was a contract with the Integrated Care Board and the hospital worked with local hospitals to support NHS waiting lists.

The provider engaged with local communities through education and outreach events, helping to support areas experiencing social deprivation. They provided examples of working with local schools to educate children on the importance of hand hygiene and provided education at local football games.

The provider promoted community events through its website, enabling members of the public to access engagement and education opportunities.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff told us they had opportunities to develop their skills and contribute to service improvement. While not all staff wished to progress their careers, they reported being consistently offered development opportunities and included in improvement work. Leaders were supportive of staff development.

The provider continued to develop its services, including the introduction of a new weight management service. This was supported by staff training and development to ensure the necessary skills and knowledge were in place to deliver the service effectively.

There were forums for discussing learning from incidents and leaders cascaded information to the relevant staff members. Staff told us they were well informed about incidents.