The Care Quality Commission
  • Hospital
  • Independent hospital

Nuffield Health Cheltenham Hospital

Overall: Good read more about inspection ratings

Hatherley Lane, Cheltenham, Gloucestershire, GL51 6SY (01242) 246500

Provided and run by:
Nuffield Health

All Inspections

During an assessment of Diagnostic imaging

We assessed diagnostic imaging at Nuffield Health Cheltenham Hospital on 25 to 26 March 2026.

We carried out the assessment of diagnostic imaging due to the age of ratings. The service’s previous diagnostic imaging inspection was under our focused methodology in August 2022 where we inspected and rated the safe and well-led key questions only. The ratings for caring and responsive were given in 2016 where diagnostic imaging was combined with outpatients. We had not previously rated effective. At this assessment, we assessed all 33 quality statements across all key questions.

Diagnostic imaging services provided included: plain x-ray, ultrasound, mammography, magnetic resonance imaging (MRI), computer tomography (CT) and dual-energy x-ray absorptiometry (DEXA) scans. The service also provided theatre radiography services.

The service carried out almost 11,000 scans in the 12 months prior to our assessment.

The quality of children and young people’s care and treatment undergoing diagnostic imaging procedures was not reviewed as part of the diagnostic imaging assessment. The children and young people’s assessment covered care for people under the age of 18.

This assessment was included as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations. This was conducted with the consent of the provider.

Safe:

The service had a good learning culture where staff and patients could raise concerns. Managers investigated incidents thoroughly. Patients were protected and kept safe because staff understood local safeguarding arrangements. There were enough staff with the right skills, qualifications and experience in the service to ensure high quality care and treatment. Managers made sure staff received training and had regular appraisals to maintain high-quality care. Staff managed medicines safely. Staff understood and managed risks from the environment. However, the service did not always label MRI equipment correctly. Stock was not always stored correctly.

Effective:

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of patient’s physical emotional, communication and personal care needs. Patient outcomes met expectations. Patient’s comfort was observed throughout the procedures. Staff made sure patients understood their care and treatment to enable them to give informed consent. Care and treatment was based on latest evidence and good practice guidance. However, printed procedures were not always in date.

Caring:

Patients were treated with kindness and compassion. Staff protected their privacy and dignity. They treated patients as individuals and supported their preferences. Staff responded to patients in a timely way. Patients had the opportunity to ask questions from allied health professionals. The service supported staff wellbeing.

Responsive:

Patients were involved in decisions about their care and treatment. The service provided information which patients could understand. Patients were invited to give feedback, knew who to speak with if they had concerns and were confident the service took their concerns seriously. Patients were involved in making decisions about their care and understood the need for the recommended diagnostic procedures.

Well-led:

There was a culture based on speaking up, listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities.

During an assessment of Outpatients

Date of Assessment: 25 and 26 March 2026

We conducted an onsite unannounced assessment visit of Nuffield Health Cheltenham Hospital. We assessed quality statements from the safe, effective, responsive, caring and well-led key questions.

The Outpatient Department at Nuffield Health Cheltenham Hospital offered a wide range of services, with 12 consulting rooms, delivered through both nurse-led and consultant-led clinics. The service was open Monday to Friday between 7.45 am and 8.15pm. The service also provided clinics on a Saturday as and when required. There were a mixture of specialities using the outpatient services which included orthopaedic, audiology, gynaecology, respiratory cardiology, Urology, ENT, Rheumatology, Neurology, Cosmetic, Dermatology and Sports Injury. The service also ran a dedicated wound clinic to support post-procedure patients.

The service received both private and NHS referrals. At the time of our assessment 97% of patients were privately funded. During the year 2025, Nuffield Health Cheltenham Hospital treated 38,692 patients.

The hospital’s core service is surgery. Where outpatient arrangements mirrored those in surgery, findings have been reported in the surgery section.

During the assessment, we spoke with staff, leaders and service users. We reviewed care records, policies, and other documentation relevant to the service.

We rated the service as good. Staff delivered compassionate, person‑centred care and described a collaborative culture where they felt well supported by both colleagues and the management team.

During an assessment of Services for children & young people

The date of assessment 25 and 26 March 2026.

Nuffield Health Cheltenham Hospital is an independent hospital within the Nuffield Health group. The hospital offers outpatient and surgical services to adults, alongside a limited range of services for children and young people. The service provides a range of surgical procedures for young people aged 16 to 17 years, following an assessment of their individual care needs. Within outpatient services, consultations are provided to children aged 0 to 3 years. Children and young people aged 3 to 17 years can have access to non-invasive procedures, including phlebotomy and nurse-led interventions such as dressing changes and suture removal. Diagnostic and imaging services for children and young people aged 3 to 17 years, include X-ray and ultrasound. For young people aged 16 to 17 years, additional procedures such as fluoroscopy-guided interventions (this is the use real-time, moving X-ray imaging (fluoroscopy) to help doctors perform minimally invasive medical procedures) are available where clinically indicated. Physiotherapy services are also provided for young people aged 16 and 17 years as part of their surgical pathway during their inpatient stay.

Between April 2025 and March 2026, there were 86 outpatient attendances for children and young people aged 0 to 15 years. During the same period, there were 312 attendances for young people aged 16 to 18 years. Surgical procedures for 16–17-year-olds from April 2025 to March 2026 there were 43. Diagnostic and imaging Children and Young People for the timescale of March 2025 to March 2026 represented 1.6% of the total images taken.

We undertook this assessment due to the timescale since the last inspection in 2016. We assessed all quality statements from the safe, effective, responsive, caring and well-led key questions.

Surgery was the core service at this location, and we will refer to this report and outpatients and diagnostic and imaging for more information regarding this location.

We rated the service as good. Staff described a supportive and collaborative culture, underpinned by effective leadership and strong teamwork. Staff understood incident reporting processes and told us that learning was shared across teams. They had access to electronic training resources, and were up to date with mandatory training. However, staff who provided care and treatment to children and younger adults had not completed safeguarding children training to the level set out by national guidance.

Safe:

The service demonstrated a positive learning culture in which staff and patients felt able to raise concerns. Incidents were investigated, and staff understood safeguarding processes to help maintain patient safety. There were sufficient staff with the appropriate skills, qualifications, and experience to deliver safe care. However, staff providing care to children and young people had not completed safeguarding training to the level as set out by national best practice guidance. There was a small, designated area for children in outpatients and younger people undergoing surgery were provided with a single occupancy room.

Effective:

Parents and/or guardians were involved in the assessment of needs of children and young people. Assessments were regularly reviewed and reflected patients’ physical, emotional, communication, and personal care requirements. Outcomes met expected standards. Staff ensured patients and their families understood care and treatment to support informed consent. Care and treatment were delivered in line with current evidence-based guidance.

Caring:

Children, young people, and their parents and/or guardians were treated with kindness, compassion, and respect. Staff maintained privacy and dignity, delivered person-centred care, and responded in a timely manner. Patients and families were given opportunities to ask questions. The service also promoted staff wellbeing.

Responsive:

Children, young people, and their parents or guardians were involved in decisions about care and treatment. The service provided clear and accessible information to support understanding. Patients were encouraged to give feedback, were aware of how to raise concerns, and were confident these would be addressed.

Well-led:

The service demonstrated a positive culture of speaking up, learning, and trust. Leaders were visible, knowledgeable, and supportive, and staff felt able to provide feedback without fear of bullying or harassment. Staff understood their roles and responsibilities and were supported in their professional development.

During an assessment of Surgery

We carried out an onsite unannounced assessment visit of The Nuffield Health Cheltenham Hospital on 25 and 26 March 2026. Surgical services provided include orthopaedic, general surgery and cosmetic procedures for private and NHS patients. The location had 3 theatres, 1 ward with 33 individual patient rooms, 1 day case surgical ward and a physiotherapy department.

We assessed 33 quality statements from the safe, effective, responsive, caring and well-led key questions. During the assessment, we spoke with staff, leaders and patients. We reviewed care records, policies, and other documentation relevant to the service.

At the previous inspection we rated surgery as good. At this assessment the rating remains good. The service had made improvements since the previous inspection however staff training compliance was still low in some areas. We issued 1 breach of regulation for safe care and treatment, as there was not enough staff that had completed the required mandatory training in some training modules. An action plan will be requested upon publication of the final report.

The service provided compassionate and person-centred care. Staff reported a collaborative culture where they felt supported by their colleagues and the management team. Staff knew how to report incidents and learning was shared amongst teams. However, we observed some areas where infection prevention and control required improvement. These were raised with staff at the time of our visit.

During an assessment of the hospital overall

We assessed Nuffield Health Cheltenham Hospital from 25 to 26 March 2026. The service remained rated good overall, all services were rated good.

The Nuffield Health Cheltenham Hospital is an independent hospital, which is part of the Nuffield Health group. This assessment looked at all services provided to include; surgery, outpatients, diagnostic imaging, and children and young people. We carried out this assessment due to the age of ratings.

In each service we assessed 33 quality statements for the 5 key questions: safe, effective, responsive, caring and well-led. During the assessment, we spoke with staff, leaders and service users. We observed care. We reviewed care records, policies, and other documentation relevant to the service.

We found a breach of regulations in relation to mandatory training.

26 August 2022

During a routine inspection

Our rating of this location stayed the same. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Bank staff did not meet the provider’s minimum target for completion of mandatory training.
  • The fabric in some parts of the building reduced infection control compliance and presented avoidable risks.
  • The persistent use of agency nurses resulted was increasing delays to discharge, although risks around these were well managed.
  • While standards of care record keeping were good, there were persistent challenges around consultant willingness to comply with provider standards in outpatients.
  • Information governance in diagnostic imaging was a known trend in incidents and had not yet been fully resolved.

15 and 16 March 2016

During a routine inspection

We carried out this inspection as part of our programme of independent healthcare inspections under our new methodology. The comprehensive inspection was carried out through an announced visit on 15 and 16 March 2016. We did not carry out an unannounced inspection.

Our key findings were as follows:

We rated the hospital as good overall, with surgery, rated as good in all domains, children and young people’s services and outpatients and diagnostic imaging services were also rated good in all domains except for effective which we did not rate due to insufficient evidence being available.

Are services safe at this hospital/service

  • Most staff spoke confidently about the duty of candour and training had been provided in some cases. However some staff were not familiar with the term duty of candour. Staff we spoke with confirmed they informed and apologised to patients when care was not as it should have been.

  • Safeguarding practices were clear and staff were aware of the actions needed if they had concerns. Staff demonstrated an understanding of their safeguarding responsibilities and an understanding of safeguarding procedures. There had been no safeguarding concerns relating to adults or children reported to CQC between October 2014 to September 2015.

  • The systems in place to monitor patient safety including the World health Organisation (WHO) checklist were mostly in place and well managed.

  • The service had a good reporting culture for incidents and took learning from those and incidents which were reported at other Nuffield hospitals. Quarterly governance meetings were held which were attended by representatives of each department and reported incidents were discussed.

  • Each patient’s consultant was the overall person in charge of their care and undertook any post treatment reviews. Out of hours the consultant was called if needed and we saw when this had taken place. In the interim the Registered Medical Officer (RMO) was available to provide medical support should the consultant not be available. An escalation procedure was in place for nursing staff to escalate to the RMO and for the RMO to escalate to the consultant for the patient.

Are services effective at this hospital/service:

  • Treatment was provided in line with national guidance and staff were aware of the relevant National Institute for Health and Care Excellence (NICE) guidance. Policies and procedures were in place to support staff and were monitored to ensure a consistency of practice.

  • Reviews took place of the effectiveness of surgical procedures. The reviews took place through the Medical Advisory Committee meetings which took place quarterly where issues, incidents and clinical outcomes were reviewed to ensure good practice.

  • The Hospital participated in the Patient Led Assessment of the Care Environment (PLACE) audit annually which was undertaken by 'expert' patients provided by the Health and Social Care Information Centre together with the Hospital's Infection Prevention Coordinator.'

    The hospital's PLACE scores were the same or higher than the England average for cleanliness, dementia, food, privacy, dignity and wellbeing.

  • Some information about patients care and treatment and their outcomes was collected and monitored. There was not always sufficient data to submit to national audits. Local audits were undertaken using a system called GOV14 to review 20 patient records per quarter for venous thrombo embolism (VTE), falls, catheter care and monitoring of the WHO checklist. Local audits were carried out in diagnostic imaging for example monitoring the quality of plain film x-ray results and levels of radiation that staff experienced while carrying out their duties. Cleaning audits were in place to ensure monitoring of the environment.

  • Systems were in place to ensure staff were competent to care for children and young people of the age range that visited the hospital as outpatients. Guidance was available and easily accessible for staff to follow if they were unsure of procedures.

  • Most of the consultants worked in the NHS and so received their appraisal and revalidation there and the information was forwarded on request to Nuffield Cheltenham. The hospital had a responsible officer in post to ensure those consultants not employed elsewhere for validation purposes were suitably appraised and revalidated.

  • Staff were aware of their duties in law when obtaining consent and ensured explanations were given to patients in a way they could understand.

  • Nuffield staff told us that the Nuffield Cheltenham does not accept referrals for patients who lack the capacity to consent, however the provider told us they did.

Are services caring at this hospital/service

  • Patient feedback about the care provided was positive. Staff were seen to be kind and caring and their focus was on individualised patient care. Patients were kept informed at all times about their plan of care and their relatives and carers were encouraged and supported to be involved in the patients care. This included both the admission and discharge process. Patient’s privacy and confidentiality was respected at all times.

  • We saw staff working with patients and those who attended outpatient appointments with them in a respectful and considerate manner. Some patients had mobility issues and staff ensured that patients and those with them were not rushed when they called patients and showed them where they were to go.

  • We chose a random selection of ten patient satisfaction survey forms from approximately 100 available in the breast care service in outpatients. All ten were positive comments.

  • The Friends and Family Test scoring system was in place for NHS surgical patients. For patients funded by any other method an alternative scoring system was in place to gather patient’s views.

  • For NHS patients the sample size was small due to the low numbers of NHS patients but the scores were high which indicated satisfaction with the service.

Are services responsive at this hospital/service

  • Services were planned to meet patients’ needs. The flow of admissions and discharges through the hospital was well organised. The needs of different patients were considered in the planning and delivering of the service. The provider was aware of further work needed to develop dementia care as part of the service and was taking action to address this shortfall.

  • Complaints were responded to in a timely manner and learning taken to develop future practice. CQC did not directly receive any complaints about the hospital between October 2014 and September 2015. All complaints, investigation findings and lessons learnt were captured centrally with review at quality and safety committee

  • Care and treatment was only cancelled or delayed when absolutely necessary. We saw evidence of reasons for when patients had appointments cancelled which were shared with patients for example delays in consultants attending the hospital. The cancellations were explained to people honestly and patients were supported to access care and treatment again as soon as possible.

Are services well led at this hospital/service

  • The vision and objectives for the service were evident and understood by staff.

  • There were clear governance processes in place to monitor the service provided. However, some areas including the management of Venous Thrombo Embolism needed further development to ensure they were safe.

  • Leadership at each level was seen to be visible and responsive. Staff had confidence in leadership at each level.

  • The senior management team were aware of the risks in the hospital and there was an effective governance framework to support the delivery of good quality care through actions from meetings.

  • Staff we spoke with described feeling part of a team and that they were respected and valued.

Our key findings were as follows:

  • Overall the service leadership was good because leaders engaged with staff and people working at the hospital and acted on suggestions and outcomes of learning from incidents and complaints.

  • Cleanliness was good in all departments and, infection prevention and control was managed well.

  • The systems in place to monitor patient safety including the World health Organisation (WHO) checklist were mostly in place and well managed.

  • Full records for children being seen in outpatients were not available to hospital staff.

  • Staffing levels in all departments were safe.

  • The hospital did not hold morbidity and mortality meetings. There were no unexpected deaths and no cases of mortality between October 2014 and September 2015.

  • All patient complications were reviewed by the Medical Advisory Committee (MAC).Patients received treatment which considered their levels of pain and their nutritional and hydration needs.

  • The Hospital had established two new services in the previous 12 – 18 months. A private breast care service which included a clinical nurse specialist in breast care, a certified complementary therapist and a private multidisciplinary team to support the four breast surgeons.

  • Complaints were managed and investigated with learning being shared within teams.

There were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider MUST take action to:

  • Ensure that all records are stored securely and there are no risks of patient confidentiality.

  • Ensure that the management and recording of venous thromboembolism prophylaxis is clarified. That risks are appropriately recorded and managed and policies ensure patient safety.

  • Maintain secure, accurate and contemporaneous patient records at the hospital, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided

  • Ensure that World health organisation checklists are signed correctly by all staff including consultant staff working in imaging.

The hospital SHOULD take action to:

  • Ensure sufficient World Health Organisation audit records are in place to provide reassurance that sufficient have been completed to provide an accurate measure.
  • Ensure that safety audits for non NHS patients are undertaken to ensure safety of all patients.
  • Improve the labelling and security of medicines prepared for operating theatres, ensuring they are disposed of within appropriate and safe timeframes.
  • Ensure leadership arrangements for services for children and young people’s services are defined.
  • Ensure all staff having contact with children and young people are trained as outlined in national guidance - Safeguarding children and young people: roles and competences for health care staff, March 2014.
  • Consider improving links with local safeguarding children boards.
  • Consider providing information suitable for young people attending as patients.
  • Consider how to gather feedback from children and young people.
  • Ensure that regular feedback on voluntary monitoring of radiation exposure levels to staff is obtained within recommended time frame.
  • Ensure that required mandatory training is completed for outpatients and diagnostic imaging staff.
  • Ensure that major incident scenarios and practice include outpatient department and imaging staff and are held to supplement the business continuity plans.

Professor Sir Mike Richards

Chief Inspector of Hospitals

13, 14 November 2013

During a routine inspection

We spoke with 19 people. Some were inpatients and other people were waiting for outpatient appointments. We also spoke with five relatives. All people had chosen to use this hospital. The feedback we received was all very positive. People felt included in their treatment plans and told about their operations in "layman's terms" .They also said they could have asked as many questions as they liked of all staff. Some of the other comments were received included; 'The staff were very good, they popped in to check on me every so often, to see I was alright." "They're busy, but no, there's not too few of them," "the staff are great, so cheerful and polite". The consultant has been super I've been in very good hands.' The feedback from people about the standard of cleanliness and food provision was also very good.

As part of this scheduled inspection we followed up on some information of concern we had received. This included concerns about some of the practices in theatres and concerns about the skills and numbers of staff. We discussed this with the registered manager and a senior member of staff who told us they were aware of the concerns and had started to put actions in place where these were needed. During our inspection we found no evidence that the care people received was negatively affected by the staffing levels at the time of our visit.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

9 January 2013

During a routine inspection

We looked at the care records for 10 people who had used the service. In every case we found the records to be accurate and up to date. Comprehensive care records were used depending on whether the person was a day case or staying overnight. These records included health screening and details of all the staff caring for that person during their stay. It was a comprehensive document with care plans and observation charts included.

We spoke to three people who had used the service. One person told us 'it's fantastic, I can't fault it here. The staff make sure I am always comfortable and they always explain everything fully'. Another person said 'There is nothing I don't like, the staff have put me at ease and it's just been perfect'. We were also told 'I know I am paying for my care here, but they are all just brilliant'.

We saw that the provider had comprehensive polices in place for infection control. As a result they have had no incidences of surgical site infections, MRSA or clostridium Difficile.

8 December 2011

During a routine inspection

We visited the Nuffield Health Cheltenham Hospital on 8 December 2011 and spent the day at the hospital. We met and talked with patients, visitors, and members of the staff team including the matron who was in charge of the hospital that day. The hospital provided treatment for people over the age of 16 years, and provided consultation for children over the age of three years and up to 16 years old. The hospital offered consultant-led consultation, outpatients' clinics and minor operations, and three theatres for surgical procedures. The hospital had one overnight stay ward with 32 ensuite rooms.

We visited all areas of the hospital during our visit, including the theatre suite, the physiotherapy department, the pathology department, imaging, the ward, ambulatory care, and the outpatient/minor operations clinic area. We talked with a number of the theatre staff, administration and support staff, radiography staff, ward staff, clinic staff, the governance lead (who gave us a tour of the hospital), and the matron in charge.

The hospital was clean and in good decorative order. Corridors, patient rooms, clinical areas and other areas were clean, well appointed and equipped. The hospital was free from obstructions and clutter. Cupboards were closed and locked where appropriate.

Patients that we talked with were positive about their experience at the hospital. One person who had visited the hospital on a number of separate occasions said "the staff were extremely helpful. The nursing staff were particularly attentive". This person also said "my stay couldn't be faulted". One person said that the food was "very good" and another said that it was "mostly good, but you don't always feel like food following surgery, so I've not eaten much." Another person said that the administration at the hospital was "excellent" and "my appointment was made very much to suit me and my other priorities." Another person said "the information I have been given was clear and they are very knowledgeable as they have fully answered all my questions".

Staff told us about working for the hospital, how they were supported and about their delivery of care. We were given information about training, development and appraisals; how privacy and dignity was maintained for patients; and how the hospital assessed and monitored care. We also looked at medicines management and checked how the hospital prescribed, stocked and administered medicines.

We inspected the hospital for five of the essential standards of quality and safety and found it to be compliant with all these standards.