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

At our last assessment we rated this key question good. At this assessment the rating remains good. 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.

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.

There was a trust strategy deployment review for surgery. The divisional leadership team had oversight of how their priority improvement work was progressing and contributing to delivery of the trust’s strategy. Leaders told us staff knew and understood the provider’s vision and values and how they were applied in the work of their teams. These were embedded by posters, intranet log-in screens, email signatures and values-based interview questions and discussion during the appraisal process. Staff said they knew and understood the provider’s vision and values.

Leaders spoke to us about the importance for staff to develop skills and were supportive of staff to seek career development opportunities. The service promoted equality and diversity in daily work and there was an open culture where patients, families and carers, as well as staff, could raise concerns without fear.

There was a health, equity and diversity group (HEDG) with staff networks designed to eliminate discrimination, reduce health inequalities, and foster inclusive, culturally competent environments for both patients and medical staff. Equality considerations were incorporated into service change processes using quality and equality impact assessments (QEIA). These were systematic evaluation processes to ensure proposed changes did not inadvertently compromise patient care. They identify measures and mitigate any potential risks to safety, clinical effectiveness, and the patient or staff experience before changes were implemented. These were reviewed by an independent panel.

Staff reported the leadership culture was inclusive and they felt valued and respected. They said the senior leadership team was visible and talked to teams.

Team and individual staff achievements and successes were recognised and celebrated. Staff were thanked for their work. Service leads recognised staff’s work and contributions during daily huddles (meetings).

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 a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Managers held direct conversations with clinical teams about service change. Senior staff said leadership support structures included weekly individual meetings with seniors, peer support with their colleagues and regular senior meetings providing cross-divisional support.

Leaders had the skills, knowledge and experience to perform their roles with a good understanding of the services they managed. They could explain clearly how the teams were working to provide good care.

Leaders responded to staff and patient feedback. Leaders took incidents seriously and knew how to respond to concerns when raised by staff which promoted a positive culture in the service. Staff told us they were well supported by senior leaders and were confident in how they led the service. They knew the leadership team and described them as visible and approachable for patients and staff. Staff felt they were heard when they raised issues.

There was a leadership approach to performance management using the respecting everyone policy, focused on early intervention, setting SMART objectives, and tailoring support to learning styles. SMART objectives are specific, measurable, achievable, relevant, and time-bound targets. They align individual roles with national healthcare goals, support clinical governance, and are typically used in annual appraisals.

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 voice would be heard.

Leaders described a supportive culture with accessible leadership including an “open door” approach. They said staff acted with openness, honesty and transparency. Staff were encouraged to raise concerns and the culture allowed staff to be confident their voices were heard. There was a respecting everyone policy as part of the approach to enabling staff to speak up and have issues addressed. Staff said when they raised concerns they felt supported. They were confident leaders would investigate concerns sensitively and confidentially.

There was a freedom to speak up (FTSU) policy which identified roles and responsibilities of staff and provided guidance about raising concerns. We observed information about freedom to speak up on a staff information board. Staff had access to freedom to speak up guardians and some staff knew who they were (guardians were trust-wide and not located at the hospital). Staff told us they would approach their line manager about any concerns first but knew they could also approach the freedom to speak up team. Leaders said the psychological safety of staff was reinforced through line management and demonstrated by people being protected and looked after if they spoke up. Staff received training in freedom to speak up and records showed 100% compliance.

The trust gathered staff views with annual staff surveys. In the unit, 51.9% of staff completed the 2025 survey which showed an upward trend on the number participating in the survey over the previous 3 years. Staff were asked if they felt their role made a difference to patients and 96.3% agreed. However, only 42.3% of staff said they felt supported to develop their potential. In response to survey results, leaders had identified priorities to sustain momentum and protect staff wellbeing.

The service also recorded patient feedback through the friends and family test (FFT). Data provided for the 12 months before our visit showed a high number of responses were received from 99% to 100%. In March 2026, comments included: “Felt very comfortable. Everything was explained.” and “Every member of staff was fantastic, patient, helpful, reassuring and kind.”

Most of the patients we spoke with at the time of the assessment rated their overall experience as “excellent” and 1 as “good”. When asked if they felt the hospital was well organised most said yes and one described it as “outstanding”.

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.

There was a trust-wide people equality, diversity and inclusion (EDI) policy. Leaders worked to create an inclusive working environment with a commitment to equality, diversity and inclusion for all 9 protected characteristics as defined in the Equality Act 2010. Leaders promoted equality of opportunity and experience for the workforce within the workplace and throughout their employment. Managers received training regarding responsibilities for making reasonable adjustments for staff and the recruitment process identified adjustment needs. Staff said the service was very flexible regarding reasonable adjustments. For example, if staff requested reduced hour working, they found management was accommodating.

The service acted to prevent and address bullying and harassment at all levels and for all staff. The trust had a respecting everyone policy. Also, a staff conduct policy provided an overview of the expected standards of behaviour and conduct for all employees. Monitoring was overseen by the trust’s human resources team and staff were able to speak up to their managers, freedom to speak up guardians and in staff surveys.

The trust’s widening engagement policy aimed to improve access to health and social care careers, attracting and developing a diverse workforce, which was representative of local communities.

There was a chapel which could be accessed by staff and service users wanting to pray or have space for quiet reflection.

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

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders described governance and accountability through organisational and divisional structures, including professional accountability, line management and divisional nursing leadership. There were formal governance routes for quality and performance including divisional quarterly reporting into a clinical quality group. The governance process oversight meetings included the surgery divisional board, patient safety group, divisional clinical governance and specialty group.

Leaders told us they used the patient first operating model (NHS England’s continuous improvement system, empowering staff to identify and sustainably resolve operational inefficiencies). Patient experience was prioritised with a view to reducing waiting times and boosting overall healthcare productivity.

Local surgery and endoscopy leads worked across sites and linked with divisional governance and board structures, supporting escalation of issues through line management routes.

There were monthly senior leaderships strategic deployment reviews involving directors, deputy directors, divisional directors, clinical chairs, chief nurses, and senior medical and nursing representatives. These meetings reviewed progress against priority projects and provided a forum for divisions to request support from directors. Leaders described them as a route to identify where additional support was needed.

Policies and procedures were held on an electronic platform (staff app) for staff to view with triggers when documents required renewing. Policies were updated and followed approval and governance processes. However, we found some policies were out of date and currently undergoing review. A clinical effectiveness group reviewed the national institute for health and care excellence NICE guidelines. There was a clinical audit and regulation lead, and clinical governance audit sessions were held every 2 months.

Leaders ensured accurate information was discussed and shared with key staff. There was a risk register where risks were clearly identified and formal logs were used to keep oversight and manage mitigations to bring to resolution. Staff maintained and had access to the risk register at service or directorate level. Staff at service level could escalate concerns when required.

The organisation held regular morbidity and mortality (M&M) review meetings to discuss any themes or trends, good practice or recommendations. Audit meetings were held bi‑monthly or twice annually across the surgical division. Clinical teams prepared morbidity and mortality reports, which were presented during audit sessions. Selected cases were reviewed through multidisciplinary team (MDT) discussions to support shared learning. Where incidents occur, the multidisciplinary team collaboratively assesses the level of harm. Key findings, learning points and communications were escalated to governance teams and disseminated across relevant departments to support continuous improvement.

Staff at all levels were clear about their roles and accountabilities. Staff could find the data they required in easily accessible formats, to understand performance, make decisions and improvements.

There was an organisational business continuity plan which could be put into operation in the event of unexpected disruption to service. The document outlined arrangements for continued delivery of service following any one of a range of potentially disruptive events.

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 and leaders collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. There was a system quality group, with commissioners, ambulance services and other local services who met to review system risks and agree joint responses. The trust worked with external agencies regarding patient pathways including local authority and mental health colleagues. There were community improvement groups (including a mental health oversight group) with divisional and director-level participation.

Joint meetings were held with multiple providers through commissioning teams. Weekly sessions included commissioners, planned care leads, GP representatives, and other providers, focusing on reviewing performance and addressing access issues.

Community engagement structures included a new community partnership group (co-chaired by the hospital’s chairman and chief nurse) intended to influence services with diverse membership selected through a nomination process.

An example of effective cross-service operational coordination occurred following a significant fire at one of the trust’s endoscopy units. This placed increased demand on other endoscopy services across the trust, prompting commissioner-led mutual aid arrangements with neighbouring providers. A temporary mobile endoscopy unit was also deployed at the affected site to maintain service continuity.

Multiple healthcare providers shared the building and leaders described inter-provider working at the hospital as close and collaborative.

The trust worked with local charities, participating in monthly business meetings and major fundraising campaigns. There was charity-funded access support, with one charity funding a local free bus service from a main train station in the nearby town to the hospital.

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 were redevelopment plans for the hospital including a chemotherapy infusion unit and staff were being trained ahead of completion. This would help address increased demand at the trust’s main hospital, help to reduce waiting lists and improve access to these services for local communities. However, this was taking time as the building is rented.

In 2025, the trust’s care navigators won the commissioning for patient experience category award at the Patient Experience Network National Awards (PENNA). The service was also runner up in partnership working to improve the experience category. The service was also highly commended in the “seeing me” award at the Southwest Integrated Care Awards 2025.

Going forward leaders were focusing on enhancing communication to better meet the diverse needs of their patient populations while using audits, data, and patient feedback to evaluate and inform service improvements. In addition, they planned to further streamline the stable cirrhosis pathway. This would involve exploring the development of a one-stop service to enable patients to complete ultrasound imaging, blood tests, and variceal screening in a single visit. This would reduce the need for multiple appointments and improving the overall patient experience.

Future planning also focussed on service development with opportunities arising from a planned organisational merger, potentially expanding on the service mix delivered at the location, for example breast and urology services.

Leaders described forward planning for service redesign and estate development, including the trust’s 10‑year clinical strategy and collaborative engagement with GPs, local enterprises, and providers to determine optimal service delivery and locations.