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.

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 service operated in line with the trust’s vision, strategy, and values. For example, staff spoke about putting patients first which was in line with the trust’s Patient First programme of work. This aligned with national guidance, priorities and trust objectives. Priorities were identified through collaboration with divisional and operational leads, as well as the patient engagement community. Through these good working relationships and partnerships with other stakeholders, the trust had developed an understanding of the local health and care landscape.

A corporate project for outpatients addressed the waiting list backlogs across the trust, alongside tackling wasted appointments due to patients not attending. The trust had a detailed plan to manage some measures that were increasing the patient-initiated follow-ups as well as looking at clinic flow. Staff were aware of measures being taken to reduce backlogs.

There was a positive culture amongst staff who worked in the outpatient department. Though some staff said they did not feel part of the wider trust. The staff told us the outpatient leadership team were approachable. Staff were engaged and passionate about the services they provided and delivering person-centred care. There was evidence of teamwork through examples of multidisciplinary working and shared problem-solving. The outpatient manager gave an example of how various members of the team had supported staff who were less familiar with the incident reporting system.

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 had policies and procedures for staff to encourage a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with felt confident to raise any concerns with their manager, however seemed unsure who else they could go to. There were no ‘Freedom to Speak Up’ information posters noted in outpatients. Managers understood the importance of staff being able to raise concerns without fear of retribution.

The recent staff survey showed 80% of outpatient staff felt able to speak up about concerns and 70% felt the organisation would address any concerns. Both were above the trust average.

In the 12 months prior to our assessment, there were no cases raised with the freedom to speak up team about South Bristol NHS Community Hospital.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

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 on the resuscitation trolleys and cannulation trolleys which were out of date yet still in circulation, meaning it could have been used on a patient. Some of the cannulation trolleys were heavily stocked, which made it difficult to ensure prompt turnover of items. A member of staff was responsible for stocking the trolleys, but it was unclear how often stock on the resuscitation trolleys were checked. There was an online system regarding maintenance of equipment, however, we found items had out-of-date stickers of last maintenance on them which could lead to confusion about whether a piece of equipment was still safe to be used.

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. The service had clear staff job descriptions. Each job role had specific roles and responsibilities and set out the expectations. Staff understood their roles and who to report to in the service.

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 for reviewing contracts.

The service had governance processes and policies which followed best practice. Staff were able to access these policies on an electronic system. Staff said new and updated policies were shared at the relevant morning huddles and through a newsletter, as they did not have monthly team meetings.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Audits included cannula care, medicines management, hand hygiene, environment and fire. There were no consent or records audits completed in outpatients. We reviewed 6 sets of patient records and noted no concerns regarding record keeping. We noted a clear system for how staff would identify a patient with an allergy.

The service ensured oversight of any external contractors performing any cleaning within outpatients.

Leaders were assured of service performance through analysis of data. South Bristol NHS Community Hospital outpatients provided regular assurance reports to the Quality and Assurance Committee. We reviewed recent minutes; some issues raised were around workforce capacity pressures due to the recent staff turnover in a small team, as well as issues around delayed discharges due to transport.

We reviewed some monthly governance highlight reports. Each had the numbers of incidents, key progress, key aims for the upcoming month, challenges, and any patient feedback.

The service regularly reviewed risks. They maintained a risk register to evaluate and mitigate risks that posed a threat to the safety and quality of service provision. There was a named person responsible for completing each action. Some risks were around the environment, these included concerns regarding the ventilation in outpatients as well as fire prevention. Other risks recorded were around the lack of medical cover onsite. It was noted a patient may become acutely unwell in particular if they are receiving an intravenous infusion in their clinic. Controls were put in place to mitigate some of the risks.

The service had an up-to-date business continuity plan for outpatients should a major event interrupt the provision of care and treatment. It was last reviewed in March 2026.

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 for raising concerns, recording safety incidents, and near misses, and reporting them internally and externally. All staff were familiar with the electronic reporting system. Lessons learned were shared to support continuous improvements in safety.

As a trust, effective collaborative relationships were established with external partners to understand the needs of the relevant population, address system-wide pressures, and to deliver services aligned to those needs.