South Bristol NHS Community Hospital

On this page

• 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 that 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.

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

The safety performance over time was good. Managers monitored the number of incidents across all locations and services and held monthly incident meetings to identify themes and trends and acted where necessary. Incidents of significant or unintended exposure (SAUE) to radiation were reported externally and fully investigated with clear actions. Between January 2025 and December 2025 there had been10 SAUE incidents. The incidents we reviewed varied in type and severity, indicating a proactive and positive reporting culture. Incidents and learning were shared across all locations. For example, managers had identified trends around wrong detector selection and had sought support from medical physics to reorder examinations on the X-ray machine to prevent this happening in future.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. Staff felt empowered and trusted to raise safety concerns or propose improvements. All relevant staff, services, partner organisations and people who used services were involved in reviews and investigations. We reviewed all incidents reported in the 12 months prior to our assessment and saw there had been 35 low physical harm and 1 severe physical harm. We saw actions had been taken in all cases and learning shared. In the case of severe harm, a radiologist advised of the incorrect referral pathway for an MRI patient with a spinal compression. Clear learning had been identified and shared amongst all staff, not just those involved in the incident.

Teams worked together to identify and share learning including dose optimisation. The service had effective arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations and reviews. The imaging service ensured unintended exposures were notified to relevant regulatory bodies. At the time of our assessment there had been 2 incidents reportable to CQC in the 5 years prior to our assessment.

Leaders and staff strived for continuous learning, improvement and innovation. The provider participated in the Quality Standards for Imaging and was working towards re-accreditation. Staff regularly worked together to resolve problems which led to improvements and better working relationships, both internally and with external partners.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service carried out comprehensive risk assessments for people who used services and staff identified and responded appropriately to changing risks to people. There were procedures for the collapse of a patient in MRI, and staff were clear on the process for safely evacuating a patient. However, these scenarios had not been practiced other than on paper.

All clinical staff received training in basic life support (BLS) and had access to onsite Advanced Life Support (ALS) trained paramedics or nurses at all static sites as part of a cross-provider agreement. Data provided showed between 73.8% and 90.6% compliance for BLS training for allied healthcare professionals, against a 95% target. However, paediatric resuscitation training data showed between 31.5% and 96.5% compliance. Evidence provided after the assessment showed a clear plan to improve compliance by October 2026. Context provided by the provider showed there had been a recent policy change within radiology at UHBW to move from only paediatric radiographers being trained in Paediatric BLS to all radiographers due to the possibility of imaging children whilst on rotation or in on call settings. This explained that the current compliance was not due lack of governance oversight but that the change was only partly implemented following the improvement plan.

The service had a policy for managing deteriorating patients. Onsite emergency cover was provided 7 days a week between 8am and 8pm by emergency nurse practitioners and paramedics through the onsite urgent treatment centre, managed by another provider. There was a standard operating procedure (SOP) which outlined the process for raising the alarm using emergency buzzers and portable radios. Staff from the UTC were trained in both adult and child immediate life support and up to date best practice guidance was available on every resuscitation trolley we looked at. For example, staff in diagnostic imaging explained the UTC team were able to treat a patient’s relative who had attended the department and had a seizure.

The service had clear local rules (Ionising Radiation Regulations) and employer’s procedures (Ionising Radiation (Medical Exposures) Regulations) which protected staff and patients from ionising radiation. However, some polices were out of date and were missing some information such as 5 Gauss lines (a line which represent where an MRI scanners magnetic field has dropped to 0.5 Tesla) and the current RPA name. Tesla is the unit of measurement used to show how strong a magnet is. Evidence provided after the assessment showed this information had now been updated.

Staff followed processes to ensure the right person got the right radiological scan at the right time. Audits from March 2026 showed 100% compliance.

The service followed the Royal College of Radiologists standards for the communication of radiological reports and fail-safe alert notifications.

The service ensured the radiation protection advisor (RPA) and the medical physics expert (MPE) were easily accessible for providing radiation protection advice. The service had Radiation Protection Supervisors (RPS) in the departments which used ionising radiation. However all staff rotated through the departments, so there was not always an RPS on site for every modality although RPAs and RPS were available remotely for advice.

Staff identified patient risks using local policies which were in line with national standards and guidelines.

Staff followed national protocols to check and ensure requests for imaging procedures were appropriate for the patient. Where there were multiple IT systems, the service ensured information was shared and accessed securely when required.

The service ensured imaging requests were appropriate and included the relevant information to allow for requests to be justified in accordance with IR(ME)R. All requests were justified by a radiographer or radiologist. Protocols for each request were recorded against the referral for radiographers to access.

The service ensured the ‘requesting’ of an X-ray or other radiation diagnostic test, was only made by staff / persons in accordance with IR(ME)R. The service held a list of approved referrers, both medical and non-medical.

Patients were provided with leaflets of ongoing advice after their procedure in a format they could understand, including easy read for children.

There were positive and collaborative relationships with external partners and transparency and openness with all stakeholders about performance. We were given multiple examples of concerns raised by staff including self-neglect of patient attending from care homes. Staff described supportive conversations with the safeguarding team when exploring if safeguarding alerts should be raised.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

The service shared safeguarding concerns quickly and appropriately. Staff employed by the service received safeguarding training at the correct level for their roles and could identify when to report abuse and how. There was clear oversight of all safeguarding incidents reported, and actions were recorded which included learning and outcomes of the incident. Staff confirmed this was shared with them through regular staff meetings and updates.

Training compliance was 100% for safeguarding adults’ level 1 and 100% for safeguarding children level 1. All staff had undertaken level 2 training in both adults and child safeguarding but had access to level 3 and higher trained staff through a specialist safeguarding team. Training compliance showed between 95.8% and 100% for adult safeguarding level 2 and 93.6% and 100% for child safeguarding level 2. All staff we spoke to knew how to raise safeguarding concerns. Staff could give examples of where they had been concerned about a child brought for a scan by a patient who was being very boisterous given the child’s injury.

For example, staff had contacted the safeguarding lead for the department when a patient attended from a care home with much higher needs than expected.

Information regarding safeguarding from abuse, sexual safety and domestic abuse was displayed where service users could see it. Staff were able to access a named or designated professional for advice 24 hours a day, although the diagnostic imaging service only operated 8am-8pm seven days a week.

The service had a chaperone policy for all patients; staff were aware of and understood the use of chaperones. Patients we spoke with were aware of the policy and those we spoke with attending for ultrasound scans had been offered a chaperone.

Staff had received training in Deprivation of Liberty Safeguards (DoLS) as part of their dementia training. DoLS is a legal framework within the Mental Capacity Act 2005 in the UK. It was aimed to help protect vulnerable individuals who lack the mental capacity to consent to care or treatment arrangements which may restrict their liberty. For example, staff had contacted the safeguarding lead for the department when a patient attended from a care home with much higher needs than expected. Data submitted showed 100% of allied healthcare professionals had completed this training.

Staff understood the principles of Gillick competence and described how if they had to ask about pregnancy, patients under the age of 18 were given the opportunity to answer away from their parent or guardian.

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.

The service carried out comprehensive risk assessments for people who used services, and these were reviewed every 2 years or more frequently if risks changed. Staff had access to all relevant risk assessments in an online database.

The service had local rules (Ionising Radiation Regulations) and employer’s procedures (Ionising Radiation Medical Exposures Regulations) which protected staff and patients from ionising radiation. Staff told us they were trained in radiation safety, but no data was submitted to support his.

The service had local policies for the risk assessment and prevention of contrast-induced nephropathy (kidney damage). These followed National Institute for Health and care Excellence (NICE) Acute kidney injury guidelines and the Royal College of Radiologists standards for intravascular contrast agent administration. Contrast is a type of dye used in some scans to make blood vessels clearer.

The imaging service ensured people (including patients and staff) who were, or may be pregnant, always informed a member of staff before they were exposed to any radiation in accordance with IR(ME)R and for staff in accordance with Ionising Radiation Regulations. Audit data showed this was not always being done in CT, however there was a clear action plan and subsequent audits showed improvement. Mitigation showed the areas of non-compliance were linked to the need for inclusive pregnancy checks on all patients to include transgender patients.

Inclusive pregnancy checks were undertaken, recorded and audited as part of the annual IR(ME)R audit programme.

Staff enabled patients to give feedback on the service they received. Patients we spoke with said they felt supported by staff. We saw evidence patient choice was respected when deciding which treatment option to choose.

The service did not have an emergency department (A&E) or a process whereby service users could be transferred from the imaging department to a ward. If a patient’s health was deteriorated, staff called 999 to request an emergency ambulance to take the patient to the nearest emergency department. There was, however, paramedics and nurses on site from another provider who responded under a service level agreement (SLA), to provide support to the patient until they could be transferred to an emergency department. The imaging centre was in a purpose-built modern wing of the building which ensured access in emergencies.

A resuscitation trolley was easily accessible to staff in the event of an emergency, which was located at the entrance to the department. The trolley was fully equipped in line with best practice guidance and checked using an online application.

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 provider had an equipment quality assurance programme and were carrying this out on all X-ray, ultrasound and MRI equipment. However, quality assurance checks did not always take place at the appropriate time as recommended by the medical physics experts, manufacturers recommendations and in line with best practice guidance. There were also gaps in online records for some mobile equipment which had been transferred to the hospital. Managers assured us the documents existed in paper format but had not been uploaded by the radiographer responsible.

Equipment was maintained and serviced in line with manufacturer guidance or whenever issues arose. Resuscitation equipment was readily available for both adults and children and staff checked it regularly.

The design, maintenance and use of facilities and premises kept people safe. The imaging service ensured non-ionising and ionising radiation had arrangements to control the areas and restrict access. Staff and carers used personal protective equipment when needed. Lead aprons and lead screens were checked annually for their integrity.

The service held an asset register which showed the ages of equipment and helped senior staff and managers plan in capital replacement projects. Backup systems supported ongoing essential service if there was a failure.

Arrangements for managing waste and clinical specimens kept people safe.

The imaging service undertook risk assessments for all new or modified uses of radiation, which took account of occupational safety as well as considering risks to people who used services. All assessments we reviewed were in date of review.

The provider undertook assessments and reviews of their activities under the Control of Substances Hazardous to Health Regulations 2002 (COSHH).

Engineering support was supplied by a mix of formal maintenance contracts and overseen by a third-party company and an in-house team. Maintenance of the scanners could be planned, and issues or breakdowns were responded to promptly. The third-party contract performance was monitored by the operations manager and fed into the overall clinical governance meetings. Managers explained a lot of routine faults and maintenance was provided by the in-house team, which had reduced overall machine down time.

The service monitored staff for radiation exposure and staff told us they saw their dose reports.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most staff had regular appraisals and one to one conversations. Data submitted for imaging staff across the whole trust showed between 66.7% and 95.2% of staff across all staff roles had received a performance review at the time of our assessment.

Staffing levels and skill mix were planned and reviewed so people always received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix compared well with the planned levels and cover was provided for staff absence.

Arrangements for handovers and shift changes ensured people were safe and allowed time for staff to plan, complete equipment checks and obtained any additional information required to perform safe scans, such as blood test results for CT and MRI contrast scans.

There were enough radiologists and radiographers to meet the demands of the service. Radiologists were available to provide advice each day.

Services ensured relevant staff continued registration with relevant bodies and gave support with revalidation where necessary.

Staff who were undergoing training, such as student radiographers, were adequately supervised in accordance with legislation set out under IR(ME)R.

Staff received training to make them aware of the potential needs of people with mental health, learning disability, autism or dementia needs. Training records across all staff groups showed training compliance was between 90% and 100% for dementia awareness. For autism awareness training, across all staff, data showed between 73.6% to l00% compliance.

Staff were given time to undertake mandatory training. Overall mandatory training compliance was 93.4% across all staff groups against a 95% service wide target. Where training compliance was below this target, the service had clear oversight of barriers and had already taken steps to address the gaps by putting on extra training.

Managers monitored sickness rates and in the 12 months prior to our assessment, across all staff groups trust wide, sickness varied between 0% and 10.9%. Managers explained there had been a peak in seasonal illnesses in January 2026 which accounted for a higher rise in sickness amongst ultrasonographers.

The provider ensured all staff underwent appropriate checks as required by Schedule 3 of the HSCA 2008 (Regulated Activities) Regulations 2014. This was carried out before staff began their employment with the service for both permanent and agency staff. We reviewed 5 sets of records and saw all required information was captured.

Safety was promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks. We viewed 3 personnel files and saw evidence of appropriate Disclosure and Barring Service (DBS) checks relevant to the role of the staff member.

We scored the service as 3. 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.

Staff took precautions when seeing people with suspected communicable diseases. Where possible, booking staff sought to obtain as much relevant information about a patient before they attended for their scan. In the event of a patient attending with an infectious disease, staff had access to onsite cleaning staff and materials. If a patient was vulnerable to infection, patients were booked towards ends of lists to minimise contact with other patients.

The service maintained high standards of cleanliness and hygiene through comprehensive infection training and staff awareness. The service had reliable systems to prevent and protect people from a healthcare-associated infection. Data showed between 93.7% and 100% compliance for infection control training for all staff roles.

Staff had access to personal protective equipment (PPE) should they require it. Audits showed good staff compliance with hygiene processes including hand hygiene and logs of cleaning had no omissions. We reviewed a selection of hand hygiene audits from all sites and saw 100% compliance. Service wide annual audits showed 98.1% compliance against all audited standards.

The service had cleaning procedures for ultrasound probes using a recognised 2 step cleaning system.

Staff were provided with clean uniform and were familiar with the uniform policy around covering uniform when travelling to and from work.

Staff we saw were all bare below the elbow and compliant with the service’s infection, prevention and control policy. However, we saw two members of staff not wash or gel their hands in between patients.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff followed the services processes for medicine administration. Medicines were ordered, transported, stored but not always disposed of safely and securely, including contrast agents and oxygen cylinders. We saw 5 vials of adrenaline and 1 vial of atropine which had expired and had been left in the CT scan room to be collected by pharmacy and was not locked away. Evidence submitted after the assessment showed a new process had been developed which was being rolled out to all relevant staff.

Staff carried out comprehensive allergy and safety checks before all scans, including those involving contrast medium. This information was stored on the radiology computer system and a warning flag alerted staff to previous allergies. Patients who attended for contrast scans were only booked if they had received intravenous contrast before with no reactions or issues.

Staff used Patient Specific Directions (PSD) for each scan which involved intra-venous contrast. We saw radiologists record this on the electronic system of the type, strength, amount and flow rate of contrast required for each scan. A Patient Specific Direction is a written instruction from a qualified prescriber to administer a medicine to a named patient following clinical assessment.

Radiopharmaceuticals, contrast media and other medicines were stored correctly and in line with manufacturer guidance.

Saline was used in vials with separate syringes, and the service had a Patient Group Direction (PGD) for this, which was in date. A Patient Group Direction is a written instruction from a qualified prescriber to administer a medicine to a pre-defined group of patients without requiring a direct consultation with a doctor.