Nuffield Health Cheltenham Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that patients and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of patients and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that patients could access care in ways which met their personal circumstances and protected equality characteristics.

At a previous assessment we rated this key question as good, but it was combined with the outpatient’s department and was under a different methodology. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff could access support from external interpretation services when required. The service had key safety information available in different languages. This included safety warnings on the entrance to the MRI area, and ionising radiation signs highlighting pregnancy risks.

The diagnostic imaging area was accessible by wheelchair and step-free access from the carpark to the diagnostic area. The service had disabled toilets and changing areas. The reception area and the waiting area had a seating and toilet facilities for patients and visitors. There was a baby changing and feeding room available.

Staff discussed people’s individual clinical and personal needs with them prior to commencing scans. Staff wore name badges and could be clearly identified. Some name badges were black writing on a yellow background to improve readability for patients with cognitive or visual conditions. Staff introduced themselves to patients when greeting them.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service was open Monday to Friday 8.30am to 6pm. They were available as an on-call service out of hours to support theatres in the hospital.

The hospital held daily huddles at the start of each day to plan care, discuss risks and issues. Staff who were unable to attend received an email with meeting notes.

Staff ensured that patients who did not attend appointments were contacted to make alternative arrangements. There were up-to-date policies and procedures to manage patents who did not attend appointments.

People we spoke with did not experience any delays or issues with their scan images or reports. Patients told us access to the service was fast and at a time they wanted.

A patient’s image or reports were sent to the referrer to review and provide the results. All patient’s we spoke with were aware of the process and told us they were well informed.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

A range of information was available to patients. Staff told us they could arrange for information to be provided in large fonts for people with eye conditions or alternative languages.

Information was available on the service’s website. This included an explanation of what an image or scan involved, how to prepare and what to expect during the appointment.

People were made aware of the costs of any diagnostic and screening procedure, where they were self-pay or had medical insurance. Staff told us they would inform people of the imaging cost prior to a person attending if the scan was arranged at short notice from consultants. All people we spoke with were aware of costs. Costs and the services terms and conditions were listed on their website.

Staff received training in cyber security. Records showed all staff had completed this training. Scan images were held securely on electronic systems and sent to the referrer securely. We observed computers being locked when not in use. Rooms were lockable and kept secure when not in use.

In the 12 months prior to our assessment there were 4 data breaches reported in the service. These incidents were recorded as low or no harm. The provider reviewed the events and took actions to prevent reoccurrence.

The hospital displayed previous CQC ratings in the hospital and on the provider’s website.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

People could raise any concerns or issues in a range of accessible ways. The service had feedback forms and complaints information displayed in patient waiting areas and changing rooms. The providers website detailed how to make a complaint.

Learning from complaints and concerns was seen as an opportunity for improvement. Complaints and concerns across the hospital were discussed in monthly clinical governance meetings. In the 12 months prior to our assessment, 1 formal complaint had been made. The service investigated and resolved the complaint.

Managers monitored patient feedback to identify areas to improve. They identified they could improve care for people with autism from feedback received. At the time of our assessment the service was reviewing ways to improve care.

Staff were aware of the complaints process and knew how to support people to make a complaint.

Patients could take any unresolved complaints to a third-party organisation or to the parliamentary Ombudsman (if care was NHS funded) or to an independent sector complaints service and this information was readily available. There were no complaints referred to the Ombudsman or independent sector complaints service in the 12 months prior to our assessment.

The service made sure that patients could access the care, support and treatment they needed.

Patients could access the service through several routes, including GP referral, private medical insurance, self-pay or through their NHS hospital. Images involving the use of ionising radiation were accepted from approved referrers.

The service monitored waiting times for each type of image or scan. Although the service did not have a process to audit performance of urgent scans, data showed in the 12 months prior to our assessment, over 98% of patients were seen within 2 weeks. However, plans to introduce a process around assessing urgent scan performance. Patients did not raise any concerns about the length of time they were kept waiting for their appointment. The service monitored the number of appointments that were not attended. In 2025 there were 62 patients who did not attend their booked appointment. Managers had plans to introduce this process.

Staff made reasonable adjustments for patients, for example patients who had mobility problems.

Managers worked to keep the number of cancellations to a minimum. When patients had their appointments cancelled at the last minute, managers made sure they were rearranged.

Free car parking was available at this location. People found car parking at the hospital adequate, but some people said there were potholes. The hospital’s risk register had identified this, and leaders were looking to resolve this issue.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

People who used the service had their needs and preferences assessed and understood by staff. They were treated with equality and in a non-discriminatory way.

Staff completed training in equality, diversity and inclusion (EDI). This training was underpinned by the Nuffield Health’s EDI policy which outlined the policy statement of the organisation for a fair and equitable workplace.

The provider’s policies had a process to check if it discriminated against protected characteristics as defined in the Equality Act 2010. Each policy had an equality and diversity declaration to show the policy had been reviewed.

The nature of the diagnostic scan procedures provided by the service meant it was difficult to differentiate outcomes for people with protected characteristics. However, we looked at data around incidents and complaints, and this did not identify adverse outcomes or inequalities for people with protected characteristics.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The nature of diagnostic procedures provided by the service meant most people attended the service once, unless multiple scans were requested as part of their assessment. People who required multiple scans told us the service arranged for images to be taken so they only needed to visit the department once.

A patient’s wish for staff not to attempt resuscitation was recorded in patient’s records. Staff knew how to identify a patient’s wishes.

Patients were provided with information about how they would receive results and from whom and any related follow up appointments. The referrer was responsible for any ongoing care and treatment needs.