Nuffield Health Cheltenham 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 patients 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 as good. At this assessment the rating has remained 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.

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.

The provider was a health and wellbeing charity who saw their purpose to improve the health and wellbeing of the nation. They aimed to help individuals achieve, maintain and recover to the level of health and wellbeing that they aspired to, by being a trusted provider and partner. This was underpinned by 5 ambitions and 4 values. Managers and staff understood the provider’s ambitions and were focussed on providing quality care for people. The staff survey carried out in December 2025 showed staff felt the provider’s values were a good fit with the things that they considered important in life.

The ambitions were built into the appraisal process. Managers told us they monitored complaints, incidents and audits to understand if the service was meeting their purpose.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive, and they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration within the service. The staff survey carried out in December 2025 showed staff felt peer relationships were very good.

Staff said they had good relationships within the department and worked as a team to provide the diagnostic imaging service. They said that there was good working between different services within the hospital, which had been improving since the new leadership team came into place.

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.

The overall lead for the diagnostic imaging service was the radiology manager. They were experienced in diagnostic imaging and worked clinically in addition to leading the service. They understood the service, how it operated and the role of imaging in improving people’s health and wellbeing.

Staff told us that senior leaders of the hospital were visible and approachable for patients and staff. They told us the senior leadership were making positive changes to how the hospital worked.

Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service.

The staff survey carried out in December 2025 showed staff scored management support as 6 out of 10. This was behind the benchmark by 2.4. There were plans to improve support, but these had not had time to see an effect at the time of our assessment.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Senior leaders told us they wanted staff to feel comfortable and confident to talk about any issues.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns; the culture allowed staff to be confident their voices were heard.

The service had a freedom to speak up policy which identified roles and responsibilities of staff and provided guidance on raising concerns.

Staff had access to 3 freedom to speak up guardians. Guardians offer a confidential alternative to raising concerns in the management structure. Staff we spoke with had not used the freedom to speak up process, but they knew how to access the guardians if they needed to. Senior leaders said that the guardians received pay and protected time for the additional responsibilities.

The staff survey carried out in December 2025 showed staff scored 7.1 out of 10 for how free they were to raise their opinions. This was 0.4 behind the benchmark. During our assessment, staff told us they would approach their line manager about any concerns and felt these would be acted upon and taken seriously.

The provider’s website detailed how people could raise a concern and how this would be investigated. There were complaint escalation routes for private and NHS funded care. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

Staff received training in freedom to speak up. Records showed that all contracted and bank staff had completed the training module.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

The provider had colleague networks for specific groups of people. The purpose of these networks was for staff to share their experiences and make improvements to the workplace.

The service had an up-to-date equality, diversity and in inclusion policy. We observed leaders being approachable and supportive to all members of staff.

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.

Senior leaders described the governance structure as supporting “floor to board” escalation and oversight of risks and performance. The system included a variety of committees and groups to ensure specialist oversight of specific areas of risk and performance. The service held radiation protection committee meetings to oversee the safe use of ionising radiation and monitor compliance against regulations. Records showed these meetings were well attended by key people, and radiation safety and performance was discussed.

The governance system monitored the safety of services. There were regular meetings involving key service managers, which provided them with oversight of risk at both a departmental and hospital level. High level department risks were escalated and monitored on the hospital risk register. Governance arrangements worked effectively. However, the processes had not identified a box of disposable curtains stored on the floor, MRI equipment was not always labelled correctly, and printed procedures were not always current versions.

The hospital had access to capital funding to replace equipment and was able to replace items found to be risks on the risk registers.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to changes. The audit process covered areas such as infection prevention control and radiation protection.

We reviewed several provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities.

Leaders made sure that accurate information was discussed and shared with key staff. Staff felt well informed on key issues and performance.

The service had a business continuity plan which would be put into operation in the event of an unexpected disruption to the service, this included a short-term disruption plan.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The hospital worked with the wider provider group to support charitable and social partnerships.

The hospital ran free of charge events where the public could attend presentations on a variety of health topics. This included event covering topics such as menopause, joint pain and spinal conditions. They also ran a free evidence-based exercise programme for men who had had prostate cancer with the aim of improving treatment outcomes. This could be booked on the provider’s website.

The service focused on improvement across the organisation. Staff actively contribute to safe, effective practice.

The service worked with the provider’s wider diagnostic imaging service to share ideas and best practice. During our assessment, managers showed several examples of how they used quality improvement methods to make positive change to the service. For example, the service had identified an emerging safety issue with MRI provision. As a result, they created a quality improvement plan to introduce systems and processes to improve safety.