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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation for safe care and treatment. The service had not ensured they had mitigated the risks of fire.

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.

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 service had systems and processes to investigate incidents and near misses. There were policies to support incident investigations.

Staff understood what needed to be reported as an incident. They told us it was important to report all incidents to keep people safe and knew how to report. Staff had effective systems to raise concerns both formally and informally. Staff were assured concerns would be addressed and feedback was received. There was a central recording system that all staff could access. Staff described the organisation as a ‘no blame’ culture.

Managers investigated incidents and shared lessons learned with the team. The most common theme from incidents was that notes did not arrive on time for the clinic, though we did not see an action plan to mitigate this risk. The manager shared a recent incident and found there had been a failure of 1 of the medication fridges. There had been no patient harm. A full investigation was undertaken and actions for visiting contractors were put in place. Learning was then shared in the daily huddle meetings. A staff member told us about a recent clinical incident and the learning that had been shared following the incident.

We received confirmation from the trust's Patient Safety Team that there had been no incidents of moderate or above harm caused by delays in waiting list for outpatients. Staff told us that there had been no never events in outpatients.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care.

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 safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood their responsibilities to keep people safe from abuse or improper treatment. Staff knew how to identify and raise safeguarding concerns. They knew who to contact for safeguarding advice. Staff shared a recent safeguarding incident and how they sought advice and completed a referral.

Patients said they felt safe. There was information about the patient’s right to a chaperone clearly displayed in clinic rooms and the waiting room. Staff had a buzzer in the consultation room should they require assistance.

All staff were required to complete safeguarding training. Staff demonstrated a good understanding of safeguarding principles. The provider required admin staff to be trained to Level 1, all clinical staff to be trained to Level 2 for both adults and children. Some senior nursing staff were trained to Level 3 adults. At the time of inspection, training for outpatients for each level was at 100% compliance. There was additional senior safeguarding support available within the trust.

The trust had a clear ‘Did Not Attend’ policy for children and young people with a clear process for both administration and nursing staff to follow. Staff completed a review of the patients’ records to identify the level of risk, and the policy defined what relevant actions the staff would take.

There was a separate waiting area for paediatric clinics. Adults attending audiology appointments had to pass through this area. A staff member from audiology would escort the patient through the waiting area to the audiology clinic room.

The service carried out recruitment checks. This included checks with the Disclosure and Barring Service (DBS) for both adults and children barred lists. There was a process to review identified risk in recruitment checks.

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 worked well with people to understand and provide care which met their needs. Risks were documented and managed, a patient we spoke with advised us the doctor had provided them with information about their care which meant they felt fully informed.

Staff communicated with patients, so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff enabled patients to give feedback on the service they received.

Patients said they were actively involved in decisions about their treatment and felt well informed about the care they were due to receive, as well as care already provided. Our observations of interactions between staff and patients supported this.

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

There were concerns regarding the environment and equipment. There were numerous fire doors wedged open throughout the outpatient department. We raised this at the time of the inspection. Leaders told us a fire risk assessment, and the use of door wedges had been included in this risk assessment. We reviewed this document dated February 2026; it stated fire wardens would close all doors upon hearing the fire alarm. The list of doors was located on the noticeboard above the resuscitation trolley which was in a central place. Whilst this practice had been documented within the fire risk assessment, the reliance on staff identifying and manually closing numerous fire doors during an emergency presented a risk.

We reviewed a copy of the building’s Fire Risk Assessment. This was completed by an external company in November 2025 in accordance with The Regulatory Reform (Fire Safety) Order 2005, Fire Safety Act 2021, Fire Safety England Regulations 2022, and Building Safety Act 2022. The premises was rated ‘Moderate’. It is noted one of the actions to be completed within 6 months was the recommendation to install, ‘An automatic holding device hard wired to the alarm system to prevent wedging fire doors open.’ At our assessment in May 2026, these devices had not been installed and there were no dates provided for when this work was to be carried out.

There was a fire alarm system, and the fire alarm was tested regularly. We also checked some fire extinguishers within the outpatients department and found they had been recently serviced. Fire exits were kept free from obstruction. Some of the staff were trained as fire wardens.

A copy of the risk register was reviewed. There was no reference to wedging fire doors open in the risk register. One of the risks in the risk register was the building not being complaint with The Regulatory Reform (Fire Safety) Order 2005. It stated the ‘Fire Risk Assessment has been amended’ and ‘Staff training has been provided taking into account the compromised means of escape.’ The gap in control was an ‘Action plan to address the structural defects for the fire compliance.’ The risk had a named person and had recently been reviewed. Another risk was in the event of high winds; fire doors may not close fully. The register states site teams were aware, and actions were being taken to mitigate this risk, though the review date was January 2023.

The ventilation system occasionally caused ambient room temperature to be too high. There was ongoing monitoring of incidents related to room temperature. There were no cold drinks dispensers, so signs were put up in the waiting areas for patients to ask staff for a drink of water. Taps in the department were frequently flushed and an audit trail was reviewed.

There was no environmental risk assessment. The paediatric waiting area was a small area where staff made hot drinks. The area was sectioned off by a secure baby gate. However, staff were observed to be walking through the paediatric area with hot drinks. There was a sluice sink in the main paediatric waiting area. We raised this at the time of inspection, and a risk assessment was completed. We were told a stair gate had been ordered to close off the sluice sink.

There was a resuscitation trolley in the main department for both adult and paediatric patients. We noted some masks on the resuscitation trolley had expired and some paediatric monitoring dots (disposable adhesive sensors) not on the checklist had expired. Leaders were aware of the masks but stated they had been unable to source a replacement and were advised to keep the masks. Some of the cannulation trolleys had significant amount of stock on them. A review of 2 of these trolleys identified several blood bottles which had expired along with 2 spill kits. We raised this to the manager who took immediate action to remove and replace.

Faulty equipment was identified and removed from use and all maintenance was undertaken by an external contractor. Some items of equipment displayed service stickers that were out of date. Leaders explained equipment maintenance records were held electronically and that service stickers were no longer routinely applied to equipment. We were told equipment was maintained and serviced in accordance with manufacturers’ recommendations and whenever faults or concerns were identified.

We requested evidence of equipment servicing and were provided with a list of work orders, including annual maintenance activities. However, the information provided did not clearly demonstrate whether all equipment was up to date with its required servicing and maintenance schedule. Therefore, the service did not demonstrate they were assured of the safety and maintenance of all equipment.

The building was clean and spacious; outpatients was located on the main ground floor and had clear signage. There was a reception with a main waiting room with accessible toilets which appeared clean with hand washing facilities. The environment, floors and equipment across the outpatients department appeared visibly clean and in good order.

Arrangements were in place for managing waste and clinical specimens which kept people safe. Staff disposed of clinical and domestic waste safely, segregated into bins and labelled in accordance with the service’s policy. Bins were located in all clinical areas.

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.

There were sufficient qualified, skilled and experienced staff to operate the service. All staff received effective support, supervision and development opportunities. Staff worked together well to provide safe care that met patients’ individual needs.

Staffing levels were planned to ensure patients received safe care and treatment. There was a small core team of outpatient staff, the manager was a band 7, in their absence staff would go to the band 6. The team supported the other clinics and led the biologic clinic. External specialist clinics from the trust brought specialist staff with them, for example ophthalmic clinics were covered by ophthalmic staff based elsewhere within the trust.

Shifts were allocated by an automated roster which was set at least 6 weeks in advance to ensure sufficient skill mix across the 5 days. Agency or bank staff were used but was limited as staff need to be familiar with the outpatient setting in order to be effective. The outpatients' team was very small; therefore, the impact of recent staff turnover was felt to be high. The vacancy rate at the time of our inspection was 25.5%.

The staff team did not have formal meetings, although the staff team met each morning prior to the clinics commencing to share important updates. The outpatient department produced a quarterly newsletter with updates for all the team including safety briefings. Staff told us they received appraisals and latest appraisal data at time of our inspection was 100%.

Staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff received the training required to do their role. Training for all trained nursing staff was 100% compliant across all courses. New staff were supernumerary. Some staff told us the training was often located at other sites which could be difficult to attend.

All clinical outpatient staff received training in basic life support (BLS) and nursing staff received intermediate life support (ILS) both were 100% complaint. Staff told us they did not have paediatric basic life support training. Paediatric basic life support was provided by paediatric trained nursing staff who attended when children’s clinics were operating. In their absence clinical support was through the urgent treatment centre.

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 recruitment files and found the provider was compliant. Appropriate pre-employment checks had been completed to ensure staff were suitable to work with patients. Professional registrations were checked on their appointment and monitored to ensure they were maintained and renewed within the required time frames. The provider ensured the relevant clinical staff continued registration with relevant bodies and gave support with revalidation where necessary.

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 understood the policies and processes for maintaining good infection control. We observed outpatient staff were bare below the elbow and followed correct hand hygiene procedures. We noted some clinical staff from other sites who were conducting the clinics there were not. There were plenty of accessible hand washing sinks available. The trust had a hand washing audit which was conducted monthly, which showed 100% compliance at time of our assessment. Staff had access to sufficient personal protective equipment (PPE).

Staff took precautions when seeing people with suspected communicable diseases. A screening tool was used at reception. One of the designated rooms would be used if any communicable infection was suspected and advice would be sought from the infection control team. The trust's infection control team confirmed there had been no mandatory reported infections reported in the outpatients department in the last 12 months.

All ward areas were clean, had required furnishings and were well-maintained. Records showed regular cleaning was being performed, though the last 2 months environmental audit was 92.9%, previously it had been at 100%. Toys in the paediatric areas were reported to be wiped down at the end of each shift however, this was not set out in policy. The service were looking to formally document this process.

A number of disposable curtains had been in place for more than 3 months. Leaders advised these should be changed every 3 months and there had been issues with replacing these. We reviewed the cleaning protocol policy which stated these should be changed every 6 months. All curtains were within the 6-month timeline.

Staff received training in preventing the spread of infections, compliance at the time of our assessment was 100%.