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 this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm. However, the service was in breach of legal regulations as recruitment records were not always complete and safeguarding training policies were not always aligned.

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.

We scored the service as 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.

The service had systems for reporting incidents and a current incident reporting policy. Staff were able to identify risks and could tell us how they would report it. Staff told us that they were confident in the process and received feedback from senior leaders. Staff felt confident to intervene to prevent immediate harm to patients.

There was a rapid post incident huddle and an after action review (AARs) following an incident. Incidents were reviewed weekly in an incident review meeting, involving the senior leadership team and heads of departments. Staff received feedback from the investigation of incidents.

We saw evidence of incidents being investigated and action being taken to reduce recurrence. However, not all actions had been embedded across the wider organisation and further work was required to ensure all teams were aware of theatre booking processes. In the 12 months prior to our assessment there were 0 serious incidents or never events reported. There were 380 incidents reported, including, documentation errors, post operative deep vein thromboses (DVTs) and medication errors. There was evidence that action had been taken in response to the incidents.

Incidents identified showed a trend of increasing documentation errors since Quarter 3 of 2024, with the exception of Quarter 3 2025. However similar incidents continued to reoccur. For example, processes implemented did not always mitigate the risk of wrong side surgery. Learning from previous incidents identified a need to make improvements to the booking process which included having the clinic letter and booking document to confirm laterality. Laterality refers to one side of the body or brain over the other. However, these were not always available to staff when booking the theatre list. Not all staff involved in the booking process were aware these needed to be available. This was raised at the time of our assessment and leaders were discussing with the team.

The hospital had ‘flash alerts’ that highlighted incidents and learning from the wider organisation. These were also reiterated in bi-monthly ward meetings to ensure all staff were aware of learning or changes implemented.

Staff understood the professional duty of candour. They understood the importance of being open and transparent with patients and families.

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 accepted both private and NHS referrals. NHS patient admission criteria was clearly defined within an electronic referral system, which allowed GPs to refer patients directly. All referrals were reviewed by nursing staff to ensure the established criteria had been met prior to admission.

Patients were assessed in a pre-assessment clinic before admission to ensure their needs could be safely met and to identify any support that would be required after discharge. Staff completed a range of medical assessments prior to surgery to ensure that the risk of complications was minimised. Any patients with a higher risk of complications would be rejected and returned to their GP. This to ensure their safety in the event of any complications arising.

The physiotherapy team assessed patients to support effective discharge planning and ensure that all necessary equipment was arranged and in place prior to discharge. Patients told us they were prepared for their discharge and knew what to expect. Patients were given telephone numbers to call if they needed support after discharge.

During our assessment we observed staff undertaking a World Health Organisation (WHO) checklist and a “stop before you block”. The world health organisation surgical safety checklist is a structured tool used in operating theatres to reduce errors and improve patient safety. The “stop before you block” is a specific safety check used before regional anaesthesia. The most recent safe surgery audit, which reviewed 10 checklists, demonstrated 100% compliance.

We scored the service as 2.

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. Records showed healthcare assistants and support workers were only trained to level 1. We were told this was an administrative error where staff were not allocated the correct level of training to complete.

The service had up to date safeguarding processes in line with national guidance and staff knew how to access them. There was a Level 4 safeguarding lead within the providers wider organisation to support staff with concerns

Staff received training in safeguarding adults and children. Records showed 91.49% of staff were up to date with level 3 safeguarding adults training, and 94% were trained to level 2 in safeguarding children.

Staff were able to describe incidents where they had followed procedures to safeguard people. Managers were confident staff could identify safeguarding concerns and supported them when an incident occurred.

The service also had a chaperone process to support people if they requested it.

The service carried out checks with the Disclosure and Barring Services (DBS) for both adults and children’s barred list.

We scored the service as 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 communicated with patients and relatives so they understood their care and treatment. Patients told us they were involved in care planning and provided enough information to ensure they understood their procedure and what to expect.

Pre-operative assessments were completed to screen patients’ medical history and patients were made aware of any associated risks in advance. Patients were given the opportunity to ask questions and provided with leaflets and online documents with explanatory videos to support their decision.

During our assessment, we reviewed 5 sets of patient records. All were completed as required, including venous thromboembolism (VTE) risk assessments, National early warning score (NEWS2) and there was evidence of multidisciplinary input. NEWS2 is a standardised system used to assess and respond to acute illness by scoring key parameters to identify patients deterioration,

We observed fully compliant emergency trolleys. There were processes to follow to transfer patients to the NHS if they required additional support or critical care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The endoscopy suite was not fully secured. Doors did not have keypad or swipe-card access and a door that did require swipe access was observed to be wedged open by raised flooring. Patients and visitors could enter the department without restriction.

During our observation, we saw visitors being let into the ward by other visitors. There was a swipe-card entry and buzzer system. However, the reception desk was not visible from the entrance. This meant that individuals could enter the ward without staff being aware. Leaders told us this had been discussed. CCTV and relocating the reception desk was being considered to mitigate any safety concerns. However, we did not see evidence that this was on the risk register.

The service had processes to check the safety of electrical equipment. We checked equipment on the surgical ward and found all items were checked. Fire exits were free from obstruction and clearly signed. Fire notices and fire extinguishers were observed throughout the ward and corridors. Extinguishers had been safety checked.

The service had up to date Legionella testing certificates and had a planned programme of work to remove dead legs from the hospital's water system. Dead legs are sections of redundant pipework where water can stagnate, creating conditions that may promote bacterial growth, including Legionella. The service was proactively addressing this risk through its ongoing water safety management arrangements.

The endoscopy washer-dryer was ageing and had been identified on the service’s risk register for replacement. Leaders were aware of the potential risks associated with equipment reaching the end of its operational lifespan and had plans to replace the unit in the near future.

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.

Permanent and bank staff had an induction relevant to their role. This included orientation of the service, time in each department to understand the service and online training.

Staff were required to complete mandatory training. Records showed most staff were up to date. Staff told us they were given enough time to complete mandatory training and received reminders before it was due to expire.

Ward staffing levels were sufficient to enable staff to carry out their roles safely and effectively. Bank staff were used routinely to cover annual leave and maintain safe staffing levels. The theatre department had recently experienced a period of workforce change and was actively recruiting to vacant posts. During this period, bank staff were used to provide cover. Staff told us they were confident in the competence and capability of the bank staff and felt they worked well as part of the team.

There was a resident doctor onsite 24 hours a day, providing medical cover and support for nursing staff. An on-call nursing and leadership team was also available for support out of hours. Consultants and anaesthetists were available to call at anytime. Staff told us that consultants were approachable out of hours and they were confident they would respond appropriately and offer guidance.

Managers ensured all new staff had the appropriate skills and qualifications to undertake their job. All staff were provided with an induction and supervision to support their development. Appraisals were carried out annually. At the time of our assessment 97% of theatre staff had undertaken an appraisal and 96% of ward staff. Outstanding appraisals were due to new starters. Bank staff received regular 1:1s and support but did not receive appraisals.

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.

There were up to date Infection prevention and control policies (IPC) and staff were aware of where to find them. Records showed most staff had completed IPC mandatory training.

The hospital followed the National Standards of Healthcare Cleanliness 5-star rating system. We reviewed the last 6 months and observed a consistent 5-star rating across the ward and theatres. We observed surgical areas were visibly clean, tidy, and well maintained. Staff were seen undertaking regular cleaning activities to support infection prevention and control. ‘I Am Clean’ stickers were in use on equipment. The service labelled equipment that had been cleaned, so staff knew it was ready for use. There were up to date cleaning schedules and an external deep cleaning company attended theatres every 6 months.

We saw staff following IPC principles both on the ward and in theatres. Staff were observed washing their hands and using appropriate personal protective equipment (PPE). Antibacterial hand wash and PPE was available for use. Hand hygiene audits demonstrated compliance of 100% in quarter 4 of 2025/2026 and 98% in quarter 1 of 2026/2027. Nail varnish and jewellery were not work and staff in clinical areas were bare below the elbow.

The service had 3 laminar flow theatres, which were designed to reduce the risk of infection. The theatres were clean, well maintained, and there were plans to replace ageing equipment to ensure continued safety and effectiveness.

The service followed safe processes to manage healthcare and clinical waste. Sharps bins were stored securely and were not overfilled. Staff followed the appropriate procedures for the safe disposal of sharps, helping to reduce the risk of injury and maintain a safe environment for patients and staff. The provider participated in Patient-Led Assessment of the Care Environment, 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.

3. We scored the service as 3. 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.

Staff had access to the Summary Care Record to support them when undertaking medicines reconciliation (a process to confirm the accurate list of a person’s current medicines). National and local guidance was available to staff to inform decisions about medicines. For example, staff were able to access local antimicrobial guidance to inform treatment decisions. Antimicrobial audits monitored prescribing compliance with these guidelines.

There were processes to ensure staff could access medicines, including out of hours. Medicines in the emergency trolley were available and staff knew where to locate these.

We reviewed emergency trolleys on the ward and in theatres. There were systems for daily checks and records were fully completed. All items were present and in date. The emergency trolleys on the ward stored medication and equipment to treat young people. Young people (aged 16 and 17 years) undergoing surgery would follow the adult surgical pathway and medicines would be adjusted accordingly. Laminated guidance sheets were provided for staff.

There were Wi-Fi controlled temperature fridges that were monitored remotely by staff and processes were followed if they went outside of temperature range.

There was a system of medicines audits, and we saw examples of changes being made to practice because of these. The Pharmacy Manager was working on an improvement programme in relation to controlled drugs following previous audit findings. The most recent audit results showed that improvements had been made. Results of medicines audits were discussed at the Hospital Medicines Management & Medical Gas Committee, resulting action plans were monitored via this committee. This committee also monitored the hospitals compliance with medicines safety alerts and took action to ensure compliance with these alerts.