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 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 remains 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 trust had a patient safety incident response policy which reflected national guidance. The policy outlined staff responsibilities for reporting, investigating and learning from patient safety incidents, and using this learning to drive improvements and reduce risks to patient safety.

It set out the responsibilities for all staff relating to recording, responding to, and learning from patient safety incidents and feeding this into improvement work to reduce risk or address gaps in systems designed to keep people safe.

Data provided showed a total of 115 incidents recorded over the 12 months prior to our visit. The highest reported theme related to the provision of equipment. The service reported no serious incidents or never events in the 12 months prior to our assessment. Never events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Leaders said they created a safe environment for raising concerns. Staff knew what incidents to report and how to report them. They were assured they would be addressed and feedback received. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harm occurring.

Managers debriefed and supported staff after serious incidents. Meetings (called SWARM) were held as soon as possible after a patient safety incident occurred. These were collaborative multidisciplinary team meetings to gather information and assess what went wrong, identify system-level improvements, and prevent recurrence.

There was an electronic system for managing incidents. We reviewed incident reports showing when SWARM meetings held, investigations conducted and action plans produced if required to reduce the risk of recurrence. Incidents were discussed at review meetings and monitored by senior management. Incidents were analysed to identify trends or themes. Staff received feedback from incident investigations. There was evidence changes had been made as a result of feedback. For example, an incorrect assumption was made about a patient which stemmed from a tick box on a care plan being misinterpreted. As a result, the documentation was changed from a box to words.

There was a trust, being open policy. Staff understood duty of candour and the importance of being open and transparent with patients and families. We observed examples of letters written to patients apologising. For example, if a patient experienced a delay in their surgery.

We scored the service as 3. The evidence showed a good standard.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The referral and admission processes ensured all essential information about patients was received to determine if patient needs could be met safely. There were guidelines for day surgery management (before, during and after surgery) and patients’ suitability for day surgery. Suitability included the type of operation, comorbidities (other medical or psychological conditions) of patients and social factors including home, GP or nursing support.

Leaders identified operational flow constraints affecting how surgical lists ran, for example, sufficient staffing to support a continuous day without a lunchtime break. Out-of-hours working was being considered.

Following procedures, patients were returned to the recovery area. All patients who had received sedation were monitored using the National Early Warning Score (NEWS2) every 15 minutes for a minimum of 30 minutes or as clinically indicated. (NEWS2 is a nationally recognised tool to identify deteriorating patients and escalate them appropriately.)

There were clear pathways for patients to be transferred to the trust’s acute hospital if they became unwell. There were clinical guidelines for the emergency transfer of patients and a standard operating procedure (SOP) for preparing medications for emergency transfers of anaesthetised patients.

With patients’ permission, we followed some patients into theatre where we observed correctly completed procedures. These included “stop before you block” (to prevent wrong-sided nerve blocks during anaesthesia) and the World Health Organisation (WHO) checklist (a tool to minimize errors, prevent complications, and improve teamwork during operations). We also saw safe, reassuring and effective communication between patients and nurses, anaesthetists and consultants.

Leaders were assured WHO checklists were completed in line with policy by completing audits. Data provided of 5 WHO checklists audited by matron showed 100% compliance.

At time of discharge from the unit, patients were informed of their follow-up plans and where relevant, patients were given information about support services, such as specialist nurses.

All the patients we spoke with, who attended for procedures at the time of our visit, said they felt safe.

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

The trust had safeguarding children and adults policies, including training standards. The policies had exceeded their review dates. However, both policies were progressing through the review process and due for approval in August 2026. A risk-assessment was carried out and the current policies remained valid.

Leaders were confident staff could identify safeguarding concerns and considered safeguarding when an incident occurred. Staff knew how to identify adults and children at risk of, or suffering from, significant harm and received training specific for their roles on how to recognise and report abuse. Staff knew how to make safeguarding referrals and who to inform if they had concerns.

Data provided showed nursing staff were 100% compliant with level 3 safeguarding adults training and 96% compliant (this represented 1 member of staff) with level 2 safeguarding children training. Other staff were 100% compliant with levels 1 and 2 safeguarding for adults and children as appropriate for their roles. Advice from a designated safeguarding link nurse was available to support staff. Staff could also access level 4 and level 5 safeguarding leads within the trust.

Staff knew how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Data showed staff were 100% compliant with harassment and bullying mandatory training. Staff also received dementia awareness training (96.5 to 100% compliant). The service carried out appropriate recruitment checks including checks with the disclosure and barring service (DBS).

The trust had a restraint and clinical holding policy and a standard operating procedure (SOP) for the use of restrictive interventions. This was to ensure staff followed safe, ethical, and legally compliant processes when considering, applying, and reviewing restrictive patient interventions, in line with national guidance. A flow chart guided staff when intervention was required and another when staff required support from the security team.

Learning from safeguarding was shared through the safeguarding governance process and clinical areas took responsibility for disseminating and demonstrating improvements. There were quarterly safeguarding committee meetings where relevant clinical leads presented safeguarding reports. The safeguarding team had not received any safeguarding incidents, referrals to the local authority or staff allegations for the service during the previous 12 months prior to our visit.

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.

Staff communicated with patients so they understood their care and treatment. We saw staff providing explanations to patients at different points in their pathway and patients told us they were kept well informed.

Information about procedures was provided to patients prior to attending. In the context of consent, clinicians discussed risks with patients to be assured they wished to continue or when patients were anxious or reconsidering going ahead. Patients could be seen in clinic with relatives, carers or representatives.

There was a policy for the management of the deteriorating patient which included NEWS2 and sepsis awareness. Guidelines ensured all registered nurses felt competent in caring for deteriorating patients. There was a standard operating procedure (SOP) for the recognition, treatment and management of sepsis, based on national guidelines. Observations included sepsis screening (using the adult sepsis screening tool) and escalation if patients showed signs of deterioration. Audits were not conducted as there was no inpatient activity in the unit.

We reviewed 5 sets of patient records and all were completed as required, including venous thromboembolism (VTE) risk assessments and NEWS2 observations.

Feedback was gathered through patient surveys and we reviewed data provided for the 12 months prior to our visit. When patients were asked if they were informed of any potential risks associated with their procedure, 97.9% said “Yes”.

We scored the service as 3. The evidence showed a good standard.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The building was light and welcoming with easy parking, a main ground floor reception and a calm environment. There was disabled access with lifts and stairs to the day surgery and endoscopy unit. There was a reception, waiting room and accessible toilets. The environment, floors and equipment across the service appeared visibly clean, clutter free and in good physical order. The flooring met the required standards.

Staff described environmental constraints and steps to mitigate privacy and dignity risks due to the unit’s layout had been taken. Measures included physical changes (doors separating reception from clinical space) and the use of curtains and barriers to reduce exposure of patients in recovery and bay areas. There was a standard operating procedure (SOP) to manage the crossover of patients in the corridor.

If there were equipment problems staff said they were addressed by the engineering team. Safety alerts were received by email and escalated internally. The service had processes to check the safety of electrical equipment which were recorded electronically. Electrical safety tests were routinely performed during planned maintenance and monitored through their planned maintenance schedule. Tests were also performed during corrective maintenance, following guidance in their planned preventive and corrective maintenance standard operating procedure to ensure devices were operating to specification. Staff also carried out visual inspections of medical devices prior to use. If a device was damaged or the service due date had elapsed, staff would remove it from service and raise a ticket with the engineers. However, we observed some equipment labels were out of date and staff addressed this during our visit.

In both theatres the facilities and surgical equipment, including resuscitation and anaesthetic equipment, was available and fit for purpose and checked in line with professional guidance. We observed staff completing checks. Equipment had servicing labels and were in date, and cannulation trays were readily available.

Data provided showed ligature management risk assessment checklists were completed. Recommendations were actioned and audited. Daily morning checks were carried out by nursing staff to ensure there were no ligature hazards.

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. Sharps bins (for medical instruments with sharp points such as blades and needles) were managed safely and were fully compliant within safe fill limits, assembly, labelling and dating.

Chemical or substances hazardous to health (COSHH) were stored safely in locked and labelled cupboards within a store room. Water testing was completed by estates staff and samples were sent to the trust’s laboratory to check for legionella bacteria. We observed the testing record folder which was signed and dated.

We observed all fire exits were clear and free from obstruction and no doors were propped open. We also observed fire procedure notices, fire alarms and fire extinguishers. We checked 3 fire extinguishers which were in date. There was emergency lighting and safety signage.

The service had previously achieved the joint advisory group (JAG) accreditation for its endoscopy service. The JAG accreditation is the formal recognition an endoscopy service has demonstrated its competence to deliver against the measures detailed in the endoscopy standards. However, accreditation had been removed when the service was asked to erect a wall between the endoscopy treatment and decontamination rooms. The building work had been completed and a date in July 2026 was awaited for the JAG accreditation team to visit with a view to accreditation being reinstated.

Environmental audits were conducted. For example, annual ventilation inspection verification of theatres, including recommendations and action plans for any improvements identified. The March 2026 report showed mainly good compliance for theatres.

Cleaning audits showed 97% to 99% compliance for the service for the previous 4 months prior to our visit. Action plans were produced following audits, detailing any dust or dirt which required attention. Patients we spoke with said the environment appeared clean.

We found the main storage cupboard was kept locked and had adequate shelving for storage of consumables. However, some boxes were located on the floor and window sills. This was raised and dealt with by staff at the time. Allocated staff were responsible for ordering consumables and checking they remained in date. We conducted a random sample check and all items were in date.

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.

Leaders had processes to follow safe staffing in line with national guidance. There was a checklist for managers to manage out of hours nurses to ensure departments were safely staffed. A safe staffing escalation standard operating procedure (SOP) clarified processes and procedures for temporary staff. Also, a safe staffing for endoscopy services standard operating procedure outlined the 3 endoscopy teams across the trust to support one another. There was a safe staffing review process conducted with organisational oversight and aligned with national guidance (the safer nursing care tool (SNCT)) for theatre and surgical staffing.

Leaders told us surgical lists were sometimes cancelled if the main hospital in the trust required additional staffing support. Staff could rotate across the trust’s 3 sites and leaders viewed the consistency of training and equipment familiarity as important. There was a dedicated endoscopy training lead to support trainee endoscopists and set out training requirements. However, some staff said they were anxious about working in different locations.

Staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. New staff underwent full inductions when they joined, supported by an induction handbook. Bank or agency staff were required to complete orientation checklists.

Over the year prior to our visit, staff sickness varied from 4% to 6% with two spikes (summer 2025) of just over 8%. There were some vacancies at the time of our assessment and a skill mix review was underway. Theatre staffing levels followed guidance set out by recognised professional bodies. There was a staff tracker to keep changes updated and to help forecasting.

Staff had received and were mainly up to date with appropriate mandatory training at the time of our assessment. Data provided showed compliance of between 92.5% and 100%. Scientific and technical staff showed non-compliance (81.2%). However, data showed 0% in 3 areas which suggested some training did not apply to those roles.

Online learning disability and autism training was 96.1% compliant. However, tier 1 and 2 training was identified separately in the data supplied (45.8% and 88.8%) which did not meet the trust’s target.

Adult basic life support (resuscitation) level 2 training (79.1%) and adult immediate life support level 3 (89.6%) did not meet the trust’s target. However, the actual numbers showed that 19 out of 24 staff had completed level 2 and 26 out of 29 staff had completed level 3. The data did not provide detail of the reasons for non-compliance, for example, sick leave.

We reviewed recruitment files and found the service was compliant with Schedule 3 of the Health and Social Care Act (HSCA) 2014. The service carried out recruitment checks and there was a process to check all staff had enhanced disclosure and barring service (DBS) checks and, where applicable, professional registration.

All the patients who attended for procedures during our visit said the staff appeared confident and supported in their roles. One patient described staff as “very competent”.

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.

There was a trust-wide infection prevention and control (IPC) policy and supporting guidance which was accessible to staff. Also, an outbreak of infection policy to support staff in identifying an outbreak situation promptly and take the correct action. The service had a dedicated infection control nurse champion.

Staff completed training in infection prevention and control. We saw staff following infection control principles including compliant handwashing and the use of personal protective equipment (PPE) such as masks and aprons. We observed staff wore no jewellery and were bare below elbows. Antibacterial hand wash was available along the service’s corridors and we observed staff in theatres using the wall mounted dispensers to disinfect their hands. There were easily accessible handwashing facilities (sinks) in the service and signage at sinks and in toilets informing people to clean their hands. However, we observed an eyewash kit in theatres which had expired. This was raised at the time and a new kit was requested.

There was a trust decontamination policy for the decontamination of equipment and reusable medical devices. The trust had decontamination services across all their sites with senior leadership oversite. Team meetings were held and learning was shared across sites. The service was fully compliant with decontamination processes. The decontamination, cleaning, inspection and sterilization of surgical instruments was in compliance with decontamination guidelines.

We observed the endoscopy procedure rooms were fully compliant with regulatory requirement. However, there was no blood spill kit. This was raised with staff and was addressed at the time.

There was a cleaning team with staff allocated to each area and sometimes agency staff were employed. Staff were trained as part of induction. There were cleaning checklists in the main toilets. Audits were conducted by supervisors with 2 weekly IPC checks and theatres were audited weekly. Audit reports were shared with staff and printouts in each area at the start of shifts. Staff said deep cleans were conducted as required. We saw staff cleaning equipment after use and there were “clean” stickers on all the equipment we observed. However, not all stickers were dated and one was out of date. This was raised at the time and addressed by staff.

Cubicle curtains were disposable, appeared visibly clean and were changed using a dating system.

There was an infection prevention and control improvement programme of monthly environment audits including cleaning, waste disposal and equipment checks. All were compliant at the time of the audit in April 2026. In the 6 months prior to our visit, audit scores showed mainly 100% compliance with infection prevention and control measures, for example, hand hygiene, catheter care and the environment.

We scored the service as 3. The evidence showed a good standard.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service had systems for the safe handling of medicines. There were processes to ensure patients received the medicines they needed.

Information about patients’ regular medicines and medical history was gathered in pre-assessment clinics to ensure staff had a complete medical history and list of current medicines the patient was taking. This aided decision making on any medicines changes which might be required prior to surgery. Staff told us this detailed planning reduced the risk of procedures having to be postponed due to issues with medicines.

Although there was no onsite pharmacy the service had systems to ensure patients could receive the medicines they needed on discharge. Patients were given both verbal and written information about their medicines.

Pre-labelled medication packs were issued to patients. Staff were aware of the processes to follow for the use of pre-labelled packs. However, they told us, on occasion medicines were packed down by nurses into smaller quantities. This not was the trust’s standard operating procedure (SOP) on the supply of pre-labelled medication packs. The standard operating procedure had expired in 2025 and had not been reviewed at the time of our inspection. Staff told us, due to the merger with another trust, there was an ongoing project to streamline and review medicines related policies and procedure to ensure they were fit for purpose across all sites.

Medicine storage areas were well organised and regularly checked by staff. However, in recovery, we saw daily checks of the medicines fridges were not taking place. Staff took action to rectify this during our visit.

Emergency medicines were available and staff knew how to access these. We saw resuscitation trolley checks were taking place regularly using a new digital “app”. Staff told us this app made it easier to undertake these checks. However, the standard operating procedure for staff to follow in relation to this process was in draft and the policy did not reflect the use of the new app.

Staff had access to national and local guidance to inform decisions about medicines pre- and post-surgery. For example, we saw staff were able to access local antimicrobial guidance to inform treatment decisions.

There was a system of medicines audits which were reviewed at medicines governance meetings and had pharmacy oversight. The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts.