Nuffield Health Cheltenham Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patients were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. However, printed policies were not always the latest version.

At our previous assessments we did not rate effective. At this assessment we have rated this good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Daily huddles were carried out in the morning to review appointments. Information from the huddle was then shared with staff so they had access to the information. Any specific needs could be planned and provided for the patients.

Staff said patients did not routinely require pain relief. Staff assisted patients into comfortable positions for imaging.

Patients had access to drinking water as needed. There was a water dispenser and a free self-serve area for hot drinks for patient use. People using the service said they had access to hot drinks.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service used the provider’s overarching policies to provide safe care and treatment. Policies we reviewed were up-to-date and followed best practice. The service had local rules and policies for staff to follow to ensure safety. However, we saw some printed local procedures were not the most current versions. This meant there was a risk staff would not be following the correct procedures. Staff removed these out-of-date procedures during our onsite assessment.

The annual Radiation Protection Adviser (RPA) audit was carried out in October 2025 and was found to be fully compliant with a few minor comments made. The audit refers to the level of compliance with the current regulations, standards and guidance relating to the use of ionising radiation in diagnostic imaging. It covers areas such as IR(ME)R 2017 procedures, protocols and records, general radiation protection records and equipment. The audit found the service had a well-established quality assurance programme.

There were systems to communicate changes in guidance through meetings and newsletters.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The team had effective working relationships with wider hospital staff members. The diagnostic imaging manager met regularly with other heads of departments and hospital leadership to exchange information.

Radiology staff worked closely with referrers to enable patients to have a prompt diagnosis and treatment pathway. If they identified concerns from scans, they escalated them to the referrer. This ensured staff could share necessary information about the patient.

Staff told us that when patients came from the wards for an image, ward staff would remain with the patient to provide continuity of care.

During our assessment, we observed safety meetings where information was shared to understand risk and manage service performance.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service had a range of health promotion information available on the provider’s website. This included mental health, men’s health, women’s health, and cancer awareness.

The service provided people with information prior to scans being performed which detailed what patients should expect during the visit and how patients should prepare for their scan.

The waiting area had a leaflet with QR codes which people could scan to find out more information on a range of health issues. For example, women’s and men’s health which included information to promote wellbeing, such as menopause awareness.

At the time of our assessment there was an outbreak of meningitis in another part of the country. Staff were aware of this, and the issue was discussed at morning safety meetings.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had a comprehensive audit process to monitor service performance. There were audits to cover safety and quality of the imaging service. Managers acted on audits findings to make improvements to the quality of care. The service carried out reject analysis (review of rejected images aimed at improving quality) and had action plans to improve performance. The service had a reject rate of 6.5% which was just outside the Royal College of Radiologists suggested reject rate of between 2% to 5%.

Staff carried out peer reviews of scans taken to check quality and safety was being met.

There was a process for the peer review of images and reports to gain assurance that scan procedures were carried out in line with national guidelines and the provider’s policies.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. We observed staff seeking verbal consent before providing care or treatment.

The service had a consent policy which was up-to-date and provided patients with written information about the consent process prior to attending for appointment. The policy also referenced how staff should seek consent from young people under the age of 18 years of age.

Staff received training in consent. Records showed all staff were up-to-date with consent training.

Patients were provided information explaining the scan prior to their appointment. Patients we spoke with confirmed they had completed a safety questionnaire and had given their consent for the procedure they had attended for.

All staff received, and kept up to date with, training in the Mental Capacity Act and Deprivation of Liberty Safeguards and knew where to access the current policies. Staff could describe how to access the policy on Mental Capacity Act and Deprivation of Liberty Safeguards. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.