South Bristol NHS Community Hospital

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 there was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of people who used services and wider communities. We checked leaders proactively supported staff and collaborated with partners to deliver care, which was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We previously rated well led as good. At this assessment this has stayed the same.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of regulation 17 for good governance as the oversight of medicines and consumable equipment did not ensure safe practice. Additionally, there was missing or out of date information in key documents such as the local rules in x-ray and MRI, although data provided after the assessment showed steps had been taken to rectify this. Quality assurance records for x-ray equipment were also missing or not up to date.

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.

We scored the service as 3. 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 service had a realistic vision and strategy for achieving the priorities and delivering good quality sustainable care. Through good working relationships, partnerships with other stakeholders, and an understanding of the local health and care landscape, the service was working to identify areas in which it could support communities and to expand services further in the future.

Managers were aware of a national shortage of some staffing groups and planned their staffing to mitigate these risks. They were actively engaged in additional training to extend some roles. Managers were liaising with universities to encourage suitably qualified staff to seek employment at the hospital.

Most staff felt supported, respected and valued which was reflected in the 2025 staff survey results. Most staff felt positive and proud to work in the organisation. Staff we spoke with told us the culture and communication had improved. The 2026 staff survey was underway at the time of our assessment.

The culture was centred on the needs and experience of people who used services. The service demonstrated an inclusive and non-discriminatory person-centred approach, ingrained in the values of the service. This was evident in everyday interactions with staff, people who used the service and the public. People felt respected, listened to and safe, and services were designed around what matters most to communities served. However, we did not see any examples of improvements made to services because of patient feedback.

Staff were proud of the service and consistently reported high levels of engagement, pride and trust in leadership. They reported the service was an inclusive, supportive and empowering place to work. Staff felt alignment with and ownership of the service’s culture, vision and values. There was also a strong emphasis on the safety and well-being of staff with multiple newsletters, events, awards and support programs open to staff. Managers gave us multiple examples of support provided to staff on an individual and personal level which took a holistic view of each staff members’ individual needs and disabilities.

We scored the service as 3. 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.

Leaders had the skills, knowledge, experience and integrity they needed. They understood the challenges to quality and sustainability, and could identify the actions needed to address them, such as identifying changing needs in the workforce.

Leaders understood challenges for the service and were very active and visible to staff.

The management structure ensured there was senior support and specialist advice for staff when the needed it.

Leaders acted where behaviours or performance fell below expected standards, irrespective of seniority or role. Managers had developed a 4-pillar approach to help new staff understand the various aspects of the role of the radiographer. These pillars helped structure and informed performance and development conversations, which took place quarterly.

There were clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and the leadership strategy included succession planning and staff development. There were plans to expand the use of apprentices.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voices would be heard.

Staff felt able to speak up without fear of retribution. Staff knew who the freedom to speak up champions and guardians (FTSUG) were and how to contact them. Freedom to speak up staff had attended additional training to support them in their role. Staff were confident in raising concerns with line managers and felt supported by them.

In the 12 months prior to our assessment, there had been no cases raised with the freedom to speak up team about South Bristol Community Hospital. The FTSUG presented an annual report to the leadership board.

Staff contributed to staff surveys, and some felt action was taken in response. For example, in response to feedback in the 2025 staff survey, leaders had developed and compiled a comprehensive action plan, based on feedback from staff.

We scored the service as 3. 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.

Staff were actively engaged so their views were reflected in the planning and delivery of services and in shaping the culture.

Staff felt supported, respected and valued. Most felt positive and proud to work in the organisation.

There was an emphasis on the safety and well-being of staff. There were monthly staff team meetings where operational issues were discussed alongside staff achievements and feedback.

The service met its statutory responsibilities for the health and safety of staff. Steps were taken to support staff, and wellbeing was supported through resources, rest, and cultivating a positive work environment. There was sensitive and non-discriminatory support for those who were struggling at work, which had a positive impact on the care they delivered to people.

Staff worked as a team and shared responsibility for providing good, safe care and resolving issues together.

Equality and diversity were promoted within and beyond the organisation. Staff, including those with protected characteristics under the Equality Act, felt they were treated equitably which was reflected in the latest staff survey.

Staff were able to request reasonable adjustments and changes to working arrangements which were considered by managers.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability, or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Not all governance arrangements were clear and effective. We found equipment, which was out of date and still in circulation, meaning it could have been used on a patient. Managers confirmed there was no formal process to flag out of date equipment, but staff manually checked all equipment (such as cannulas) before use.

Leaders did not always maintain oversight of the governance arrangements for medicines management. We saw multiple vials of emergency medicines which were out of date. These medicines were inside the CT scan room, but were not marked up as awaiting disposal, so there was a risk they could be used in an emergency. Following our assessment data was submitted which showed new checklists had been implemented to included date checks on equipment and medicines.

Governance systems were proactively reviewed to ensure they remained fit for purpose, proportionate and responsive to emerging risks, system changes and population needs. Reviews occurred annually and were overseen internally. However, we saw key document such as local rules, had not been updated to contain the latest information about the Radiation Protection Advisor. In MRI, local rules were missing information about the 5 Gauss line and there were multiple versions of the local rules in circulation. The 5 Gauss line is a line which is visually marked to show the area at which the MRI scanner magnetic strength has fallen to 0.5 Tesla. This means some MRI conditional equipment can be brought into the scanner as long as it does not pass this line. Evidence submitted after the assessment showed this had now been updated.

The service collected feedback from patients, but there was little evidence of any changes made as a result of this feedback.

Online information was out of date, and we could not see anything about CT or MRI on the hospital website.

Staff at all levels were clear about their roles and they understood what they were accountable for, and to whom. Organisational structure charts and governance structure charts were clear and accessible to staff.

Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promoted coordinated, person-centred care. There was a comprehensive structure tor reviewing contracts.

There were a range of committees with specialist responsibilities. For example, the radiation protection committee (Diagnostic Radiation User Group meeting) reported incidents and actions to the overarching radiology review management group meeting. Minutes from meetings were detailed and clear with evidence of actions taken.

Leaders were assured of service performance through analysis of quantitative data, qualitative insight, audit, lived experience and external assurance. Focus was on patterns, trends and root causes, rather than isolated metrics, and this intelligence was used to challenge, learn and improve.

There was a systematic programme of clinical and internal audit to monitor quality, and systems to identify where action should be taken. The audits were reviewed at the relevant committee meetings and reported to the overarching governance committees. For example, there was a weekly focus on reporting backlogs.

Service leaders ensured lessons were learned when there were data security breaches, and the service had a comprehensive information governance policy. Data showed between 80% and 100% across all staff groups had completed information governance mandatory training against a 95% target. There had been no recorded breaches at the time of our assessment.

Risk registers were clear and up to date and there was alignment between the recorded risks and what staff said was ‘on their worry list’. For example, the service clearly recorded the risks around total equipment failure and possible anaphylaxis following contrast administration in MRI.

Potential risks were considered when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities. For example, the service had undertaken comprehensive risk assessments for each imaging modality to cover loss of power and IT failure which may result in delays in patients receiving either their scan or subsequent report.

The service implemented external alerts such as Medicines and Healthcare Regulatory Authority (MHRA) or patient safety alerts through regular team meetings which were minuted and disseminated to those who were unable to attend. Where serious enough, staff kept written records to confirm which staff had seen the alert or update.

Leaders maintained oversight of the governance arrangements for medicines management through use of a third party who prepared and stocked emergency bags. These bags were then subject to regular checks by staff including the onsite paramedics who reported any issues or discrepancies.

We scored the service as 3. 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.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally. All staff knew how to report incidents using the electronic system.

The service reviewed and investigated safety and safeguarding incidents and events when things went wrong. All relevant staff, services, partner organisations and people who used services were involved in these reviews and investigations.

Learning from lessons was shared to make sure action was taken to improve safety. Senior staff and medical physics staff attended dose optimisation meetings where discrepancies from dose audits were discussed, and actions identified.

There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs. For example, the local area was due to expand with the building of 1800 new homes which would impact services, but we did not see any comprehensive plans on how the service was planning to cope with an increase in demand.

We scored the service as 3. 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.

There was a systematic approach to continuous quality improvement, which leaders understood was key to delivering high-quality care.

Leaders and staff strived for continuous learning, improvement and innovation. For example, a review of the existing process to action significant or unexpected findings had identified several inefficiencies. Members of the administrative team had to open reports to check whether urgent findings had been acted upon. In response, the service developed a new process to route all reporting alerts to a centralised mailbox. This meant staff could monitor the mailbox, view actions taken by colleagues, and avoid duplication of work.

The service had achieved external accreditation from multiple organisations including Quality Standards for Imaging (formerly Imaging Services Accreditation Scheme). They also held various health and safety accreditation including ISO 9001, ISO 14001, ISO 45001 and BS70000. ISO accreditation means an organisation demonstrates its competence to audit and certify its management systems. QSI is an external framework which outlines what high quality imaging services should like in practice.

The service invested in its people to ensure quality improvement was embedded in the work of all its staff. There was a clear strategy for developing staff capabilities.

Staff were able to allocate time to work together to resolve problems and to review individual and team objectives, processes and performance. This led to improvements in patient care and better working relationships within the service and with partner agencies.

Leaders fostered an open culture of trust, which was honest about challenges and mistakes, and used these as opportunities for learning. Leaders actively listened to staff, monitored and assessed improvement and innovations, and enabled collective problem solving and continuous improvement.