Nuffield Health Cheltenham 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. People received treatment and care to reduce the risk of avoidable harm, which included following safety standards related to exposure to radiation and safety checks prior to entering the MRI. There were safety processes arranged before procedures started, with staff working together to ensure the right patient had the correct imaging. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. However, MRI equipment was not always labelled correctly. There were some items stored safely in storerooms.

At our last assessment we rated this key question as good. At this assessment the rating has remained good. This meant people received safe care and treatment.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated safety events. Lessons were learnt to continually identify and embed good practice.

The service had a current incident policy, which reflected the national guidance.

We saw evidence of incidents having been investigated, and action taken to reduce the risk of recurrence. We looked at the system for managing incidents which was electronic. In the 12 months prior to our assessment there were 33 incidents reported. All incidents were reported as near misses, low or no harm to people. Managers reviewed incidents and took actions to prevent reoccurrence. Records showed, actions were allocated to staff and signed off when completed.

There had been 0 reported incidents requiring reporting under Ionising Radiation (Medical Exposure Regulations (IR(ME)R). Providers must report incidents where a patient receives a much greater dose of radiation than expected.

There had been 0 reported 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.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. They spoke of the importance of reporting near misses to prevent a future serious incident.

Where there was an immediate risk to patients or others, staff felt confident to intervene to prevent harm occurring.

Staff understood the professional duty of candour (legal and ethical obligation to be open and honest with people when something goes wrong in their care). They understood the importance of being open and transparent with patients and families. Managers understood statutory requirements of duty of candour under the Health and Social Care Act.

Staff received feedback from the investigation of incidents. Incidents were discussed and learning was shared in staff meetings.

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

There was an admission criterion for both private and NHS patients. These criteria set out who could be seen safely at the service.

There were systems and processes to ensure the correct patients were treated throughout the patient journey and they only received the procedure which was intended. Suitably skilled and qualified staff accompanied patients in all areas and undertook the required diagnostic procedure.

Staff completed risk assessments for each patient on arrival, using a recognised tool. The service used The Society of Radiographers “Pause and Check” system. Pause and check consisted of the 3-point check to correctly identify the patient, as well as checking with the patient the site to be imaged, the existence of previous imaging and for the operator to ensure the correct imaging modality was used. We observed staff always using the 3-point demographic checks in line with the correct procedure.

All patients were required to complete MRI safety questionnaires. The safety questionnaires included asking patients if they had cardiac, defibrillators or other devices in their chest, and patients were asked if they were pregnant. We saw these were completed. Other visitors such as family members were asked to complete a visitor’s safety questionnaire prior to the scan. Gowns and scrubs were available for patients to change into if their clothing contained metal, such as metal zips. All referrals included patient identification, contact details, clinical history, the examination requested, and details of the scan referrer.

The IT connectivity was consistently available across the service to meet the needs of staff completing records.

The service used reporting radiologists who worked remotely. There were processes to ensure they were using equipment that met required standards for reporting equipment.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

During our assessment, we observed staff communicating how results would be received. All patients we spoke with understood how they would receive results.

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.

In the 12 months prior to our assessment, there had been no safeguarding concerns raised to the local authority. Managers were confident that staff could identify safeguarding concerns. They said they also considered safeguarding when an incident occurred or a complaint was raised.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff. Staff could access a level 4 trained person within the provider’s wider organisation.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 2 for safeguarding adults. Records showed all contracted and bank staff had completed training. For more information on safeguarding children and young people, please see the assessment for children and young people.

Staff received training in learning disabilities and autism. Records showed all staff had completed the training module.

The service had an up-to-date chaperone policy. There were chaperone posters in the department. Records showed that staff noted when a chaperone was used. However, not all staff understood the role of a chaperone. The primary role of the chaperone is to protect clinicians from unfounded allegations of misconduct, to act as a patient advocate and offer support, and protect patients form inappropriate behaviour from clinicians.

The service carried out appropriate recruitment checks. This included checks with the Disclosure and Barring Service (DBS) for both adults and children barred lists. There was a process to review risks identified in recruitment checks.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with patients to understand and manage risks. The care met patients' needs in a way which was safe and supportive.

Staff communicated with patients so that they understood their care. We observed staff providing an explanation of an MRI procedure and confirmed that they understood the procedure. Patients told us they were well informed.

The service had pregnancy status forms for all patients to complete aged 12 to 55 regardless of their gender. This was to prevent accidental radiation of exposure for all patients capable of being pregnant.

We spoke to 15 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

There was a resuscitation trolley available, and checks were completed to ensure it was correctly stocked. Paediatric and adult resuscitation policies were available as well as resuscitation council guidance.

Staff received training in life support. Most staff had completed training in basic life support. Records showed 92% of contracted staff and 100% of bank staff had completed basic life support training. Records showed 83% of contracted staff and 75% bank staff had completed paediatric basic life support. Managers had training booked for staff who had not completed the modules.

There was a process for dealing with a medical emergency within the MRI scanner. Patients could summon assistance and help as needed through the use of call bells and we saw patients were shown this. There were emergency alarm cords in changing areas.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The MRI area had a patient trolley and preparation trolley that were not adequately signed as being safe or not for use in the magnet room. Equipment used in the MRI room must be safe to use near a static magnetic field. The Medicines and Healthcare Products Regulatory Agency (MHRA) recommend that no equipment should be taken into the MRI area, particularly the magnet room, unless it is safe or can be used in specific conditions. During our onsite assessment, staff added temporary warning signs to the equipment while awaiting delivery of permanent signs.

Rooms where ionising radiation was used had permanent warning signage, and illuminated warning lights were used when an x-ray exposure was in progress.

The service practiced evacuation of the MRI. This was to check patients could safely be evacuated from the MRI magnet room in case of an emergency.

Staff carried out quality assurance processes to ensure equipment was functioning as expected.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment.

The design of the environment followed national guidance around the built environment. Access to examination rooms was restricted by a keypad lock. We observed doors secured at all times.

There was signage which detailed the magnet strength and safety rules. The MRI scanner was fitted with emergency buttons which stopped scanning and switched off power to the magnet.

There was suitable equipment provided which was used correctly for patients who needed assistance with their mobility or to transfer onto scanners. Staff carried out daily safety checks of specialist equipment. There was testing of portable electrical equipment. Weighing scales were calibrated. There were emergency procedure sheets for the MRI scanner.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction. Records showed that all staff had completed mandatory fire training. However, not all staff were confident on what to do when an alarm sounded.

Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair or replacement of broken or missing equipment.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the provider’s policy. Sharps bins were managed safely.

Chemicals or substances hazardous to health (COSHH) were stored safely and information about products was available to staff. Staff knew how to access this information.

The service had a process to visually check and test the effectiveness of lead aprons. The service monitored staff exposure to radiation.

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.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care. The service deployed radiologists, radiographers, radiology assistants, and administration staff.

Staffing was planned in advance to cover each imaging modality and to maintain safe staffing levels in MRI where 2 staff members needed to be scheduled. Records showed staff were scheduled to modalities which they were suitably trained to perform.

The service had no vacancies at the time of our assessment.

The staff absence rate was 3%. During our assessment staff told us that when absence occurred it could be a struggle to perform all imaging, but safe staffing was always covered. The staff survey carried out in December 2025 showed staff felt there was a shortage of staffing. Managers had taken action to increase staffing numbers.

The service had access at all hours to medical advice if needed.

New staff had a full induction when they started work. This included orientation of the service, responsibilities within the department, and competencies to use specific equipment. Staff said they felt the induction helped them settle into the hospital.

The staff survey carried out in December 2025, showed staff felt there was a lack of continued professional development opportunities. During our assessment staff told us they would like to have access to learning to expand their skills, but this was only available if there was a business need and was directly related to their role. There was additional learning available. The service had learning sessions and access to imaging presentations by manufacturers of imaging equipment.

Managers supported staff through constructive, recorded, annual appraisals of their work and regular clinical supervision. At the time of our assessment all staff had received appraisals. All radiologists were required to provide evidence of appraisal and re-validation.

There were processes to deal with poor performance.

Medical staff were mainly employed by NHS organisations and had practising privileges to work within diagnostic imaging. Evidence was provided to demonstrate that all medical staff were up to date with General Medical Council registration, Disclosure and Barring Service status and indemnity insurance was in place.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The department was visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

Staff cleaned equipment to prevent the spread of infection. The service had a high-level disinfection system for ultrasound probes that allowed highly effective decontamination and traceability. Traceability is the documented record linking the specific probe to the decontamination history and the patient it was used on.

The service managed infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. However, there was a box of disposable curtains stored on the floor in a storage area. Staff removed these items during our assessment.

There was a provider infection, prevention, and control (IPC) policy and supporting guidance that was accessible to staff.

There was a programme of IPC audits. For example, hand hygiene, standard precautions, and aseptic non-touch technique. Records showed the service was performing above 92% in these audits with 100% being achieved in hand hygiene in the first 3 months of 2026.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

We saw staff following infection control principles including handwashing and the use of personal protective equipment (PPE).

Staff understood the process for managing spillage of body fluids in the department.

Staff supported IPC measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

Staff completed training in IPC and management of sharps. Records showed that 83% of contracted staff and 50% (2 members of staff) of bank staff had completed IPC practical modules. However, managers had booked training for staff who had not completed the module.

People using the service told us they found the diagnostic area and facilities clean and tidy. The provider participated in Patient-Led Assessment of the Care Environment (PLACE), which is a review of the care environment from patients and staff. Results showed the hospital scored 100% for cleanliness.

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 safe systems for the appropriate and safe handling of medicines. Processes were in place to ensure people received the medicines that they needed. Practitioners had access to the medicines required during planned diagnostic procedures and pharmacy supported this ongoing supply. Pre-populated proformas were used to prescribe medicines with the aim of reducing the risk of prescribing errors.

Emergency medicines were available if needed and staff knew how to access these.

A limited range of medicines were prescribed suitable for the procedures being undertaken. Prescribing was protocolised to reduce the risk of error.

A system of medicines audits was in place at the hospital. The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts.