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 with a clear set of organisational values, which were publicly available on its website and reflected throughout the service.

Leaders were aware of the values and focused on driving and improving patient experiences. Leaders promoted an open and inclusive culture, encouraging staff to contribute ideas and feedback. Staff described feeling supported by their managers and were committed to delivering high-quality, patient-centred care. The service demonstrated a focus on continuous improvement, with feedback from staff and patients used to inform service development and organisational priorities.

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 a range of knowledge, experience and abilities to run the service and understood and managed priorities well. They could explain service risks and areas that required development. They were actively working with staff to ensure high quality care in all areas.

Leaders were visible, approachable and inclusive. Staff told us they felt supported in their roles and were encouraged to progress and develop their skills.

Leaders responded to staff and patient feedback. Leaders developed a ‘You Said, We Did’ action plan in response to staff feedback, outlining actions taken and planned improvements. Staff provided examples of service improvements implemented in response to patient feedback, including the development of a physiotherapy video to support patients’ understanding of post-surgery expectations and symptom management.

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 service provided several opportunities for patients to give feedback throughout their treatment. Patients received online surveys and questionnaires asking them about their experience. Responses were reviewed by each department and actions taken to drive improvement.

The service had a 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 told us they would approach their line manager in the first instance and felt comfortable doing so.

Staff received training in Freedom to Speak Up. Records showed, 90% of permanent staff and 93% of bank staff had completed training. Staff told us they were confident raising concerns and felt actions would be taken where needed. Managers told us staff approached them directly to discuss concerns.

The provider’s website detailed how people could raise concerns and how they 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.

The service had an equality, diversity and inclusion (EDI) policy and staff were aware of where to find it. Leaders promoted equal working opportunities and development within the workplace. All staff had opportunities to develop and progress and were supported to do so.

The service addressed bullying and harassment at all levels and formally reinforced expected standards of behaviour among staff.

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, ensuring 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 practice privileges that we found during our assessment.

The service had an action plan relating to their data breaches. One action had identified unsecured records with a completion date of October 2025. However, we observed patient identifiable information unattended in the endoscopy reception area that was accessible to the public.

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.

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. For example, water system flushing was undertaken on a regular basis while works for dead legs to be removed were underway.

There was a medical advisory committee (MAC) 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 department. Leaders also cascaded relevant information in team meetings and highlighted important information for the team to read.

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 (ICB) and the hospital worked with local hospitals to support NHS in reducing 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 service focused on improvement across the organisation. Staff actively contribute to safe, effective practice.

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.