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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our previous assessment, we rated outpatients as good. At this assessment, we rated outpatient services as good. This meant people were safe and protected from avoidable harm.

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.

We scored the service as 2. The evidence showed some shortfalls. Lessons were not always learnt to continually identify and embed good practice. The service did have a proactive and positive culture of safety based on openness and honesty. They did listen to concerns about safety and investigated and report safety events.

Lessons were not consistently learned from incident reporting or from the identification of themes and trends. Over the past 12 months, 185 incidents were recorded, 89 of which related to specimen errors. These were most often issues with phlebotomy, blood samples taken during outpatient appointments and optimisation clinics. Optimisation clinics were designed to identify medical issues that could be addressed before a surgery date was confirmed. This included carrying out standard tests and taking blood samples. When a blood sample could not be used it caused inconvenience to the patient who had to attend another appointment. The service was aware of the issue around specimen errors but initial actions did not solve or prevent reoccurrence.

Training and competency assessments relating to blood collection were delivered in Summer 2025. This resulted in a reduction in incidents; however, a further 32 incidents were reported during February and March 2026. The service completed a learning review of this process in March 2026 and identified additional improvements to strengthen the governance of blood collection and sample labelling. These improvements had not yet been implemented at the time of the inspection.

There were effective systems to raise concerns both formally and informally. We reviewed incidents, some of which staff described to us at the site visit. We found these were reported and investigated as necessary. Staff received feedback on incidents they had raised and incidents were discussed at daily safety huddles to share any learning.

Staff understood the duty of candour regulation and the need to be open, honest, and transparent with people when things went wrong with their care. Staff told us about examples where they had carried out duty or candour.

We scored the service as a 3. The evidence showed a good standard. The service worked with people to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was collected to determine if the patient’s needs could safely be met. There was an admission criteria policy for patients who used the service which helped to ensure the patients’ needs could be safely met by the organisation. If a referral was marked as urgent or a ‘2 week wait,’ it was fast tracked to the clinical team for triage and allocated to the next available appointment. Consultants had been asked to increase clinic capacity to accommodate the urgent patients. The service aimed to review all referrals within 24 hours and patients were contacted within 48 hours of receiving the referral. Leaders informed us that this was achieved.

The department worked effectively with other hospital services, including physiotherapy and the pre‑assessment clinic. During our site visit, we observed 6 consultations. Patients were seen by their chosen consultant unless a referral to another specialist was clinically indicated.

Patients, following surgery, had follow up appointments with the relevant consultant to ensure there were no difficulties post-surgery. Patients had their wound checked by the outpatient nurses or visited their GP. This helped to ensure continuity of care.

Care records were paper based and not electronic. The service was in the process of moving to an electronic patient information system. The service had listed the lack of an electronic patient record as a risk on its risk register and had implemented mitigating actions. Consultants were encouraged to write contemporaneous notes in the hospital medical record file and to complete an outcome form. There was an improvement process for contemporaneous notes which had started in February 2026. Medical secretaries (internal and external) were aware that clinic letters should be emailed or posted to the Cheltenham Medical Records team within 10 working days to ensure patient records were complete. There was a process to monitor whether this process was followed. Recent audits for quarter 1, 2026 showed 90% of clinic letters were received within 1 week of the actual clinic date. We reviewed 5 patient records and found that all the information was completed.

The service had a deteriorating patient policy which clearly set out roles and responsibilities for the health care team. It was clear that in an emergency the patient should be transferred to the local trust. Staff we spoke with were clear that they contacted the emergency services in the case of a deteriorating patient.

The outpatients department oversaw the pre‑assessment clinic, which patients attended before undergoing surgery. Based on set criteria, some patients were eligible for a telephone consultation with a nurse, while others were required to attend in person. Staff showed us the criteria they followed to determine whether a patient was suitable for surgery at this location. Preadmission staff could also refer patients to an anaesthetist if they had any concerns. We observed a patient being assessed in the clinic and noted that the assessment was thorough, with clear and effective communication between the nurse and the patient.

We scored the service as 2. The evidence showed some shortfalls. Staff were not all trained to the correct level of safeguarding. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

All staff were required to complete safeguarding training. At the time of inspection, only 75% of staff had completed Safeguarding Children & Young People Level 2. This was below the provider’s target. Training was monitored by managers and staff who had not completed training were supported to do so. All staff had completed Safeguarding Adults Level 1 & 2. Please see Children & Young persons report for further information regarding children’s safeguarding training levels 3. The service had a member of staff who was part of the wider Nuffield Health team who was trained to level 4 should their advice be required. There was a clear process for staff to raise safeguarding referrals and staff we spoke with were able to confirm the actions they would take.

Patients we spoke with during the inspection said they felt safe. There was information about the patient’s right to a chaperone clearly displayed in clinic rooms and the waiting room. Health care assistants were used to provide a chaperone for patients should the patient not have their own chaperone. Staff received chaperone training.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. 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 well with people to understand and provide care which met their needs in a safe and supportive manner. Risks were documented and managed, and patients said the consultant gave them information about their care which meant they felt fully informed.

Across the 6 outpatient clinics we observed, consultants allowed patients ample time to ask questions and clearly explained treatment options to support informed decision‑making. They gathered the necessary information to assess potential risks and provided clear explanations about any associated concerns.

The resuscitation trolley had daily checks undertaken. Paediatric and adult resuscitation policies were available as well as resuscitation council guidance. Staff received training in life support and training data indicated 100% of staff were trained in basic life support.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Outpatients had undertaken a structured assessment of environmental risks. We reviewed documentation showing that identified risks were clearly recorded, along with the actions taken to mitigate them. For example, risks relating to electrical fittings, equipment, and fire safety had been formally noted. Existing control measures included staff reporting any damaged fittings, avoiding the use of extension leads, switching off equipment at the end of each day, and ensuring all portable electrical appliances were included in a scheduled inspection programme. We confirmed that equipment had been checked and was within the required inspection dates.

The service had sufficient and suitable equipment to support safe patient care. Equipment and stock in the clinic rooms was checked monthly. We saw evidence that this process was audited. We carried out random checks of consumable items in the consulting rooms and saw that they were all within their expiry dates.

The environment was clean, well maintained, and appropriate for its intended purpose. Curtains were replaced every six months, or sooner if soiled. However, the sinks we reviewed did not meet infection prevention and control requirements relating to splash areas. This issue had been recorded on the risk register, and the service was in the process of reviewing the sinks to ensure compliance.

Clinical waste was managed safely and in line with required standards. Domestic and clinical waste bins were clearly labelled, segregated, and emptied regularly, while sharps and other hazardous waste containers were stored correctly. During our observation of a minor procedure in outpatients, we saw that all post‑procedure clinical waste was disposed of, with sharps bins readily available and used correctly.

The environment was accessible to patients in wheelchairs. Consulting rooms were spacious and wheelchair friendly.

We scored the service as 3. The evidence showed a good standard. Staff received effective support, supervision and development and they worked together well to provide safe care that met people’s individual needs. The service made sure there were enough qualified, skilled and experienced staff to care for patients.

Staff had received and were up to date with mandatory training. Mandatory training completion rates were 91%. Staff had a clear competency framework for various outpatient procedures such as performing venepuncture (obtaining a blood sample from the vein). We saw competencies were monitored by senior leaders and all staff had either completed their competencies or these were in progress. Training was monitored and staff were prompted by emails and at team meetings.

Staff received regular appraisals. At the time of inspection 85% of staff had received an appraisal with dates booked into the diary for any staff who had not had an appraisal. Staff said they felt supported by their managers.

Staff and consultants worked well together to provide safe care that met people’s individual needs. There was medical cover provided by a resident doctor. Outpatient staff told us the medical team were approachable and readily available to answer any queries.

We reviewed a sample of recruitment files and found the provider was compliant with relevant regulatory requirements. Pre-employment checks had been completed to ensure staff were suitable to work with patients. Professional registrations, including Nursing and Midwifery Council (NMC) registration where applicable, were checked at appointment and monitored to ensure they were maintained and renewed within the required timeframes.

However, there were insufficient permanent staff to fully support outpatient activity The service maintained safe staffing levels using bank staff, agency staff and overtime. At the time of inspection, there were 8 vacant posts, including 4 healthcare assistant roles, 2 staff nurse positions, and a fixed‑term senior nurse vacancy. The service was actively recruiting for these vacant positions.

Between March 2025 and February 2026, bank staff usage averaged the equivalent of 2.6 full‑time employees. On the day of our visit, a healthcare assistant from the surgical wards had been redeployed to support the outpatients department. The service was actively recruiting to fill vacancies, with two interviews for healthcare assistant posts scheduled for March 2026.

The service had recently reviewed its staffing and what staffing level was required. This determined 19.23 full time equivalent (FTE) were required to staff the outpatient department, albeit there were variations in outpatient demand depending on the clinics that were scheduled. For the last 6 months the actual FTE position was below what was required for every month excluding January 2026. In February 2026 there was 15.41 FTE compared to the required 19.23 FTE.

Turnover for the outpatient department for the last 12 months was 21%. Sickness was well managed at 2%.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The overall clinic environment, including the toilets, was visibly clean. We observed effective infection prevention and control (IPC) practices, alongside safe management of hazardous waste and sharps. Cleanliness was maintained by both the dedicated housekeeping team and clinical staff.

A weekly cleaning log, completed by outpatient staff, listed all items requiring cleaning and recorded whether each had been completed. Most clinic room items were cleaned consistently.

The service carried out regular hand hygiene audits, consistently achieving scores above 86%. In the most recent audit, conducted in start of 2026, the service achieved a score of 92%. A five‑star rating system was used to assess overall cleanliness, with five being the highest rating. Over the past year, the service consistently achieved four or five stars, including a five‑star rating in February 2026.

We also saw evidence that staff were notified when compliance issues were identified, such as the wearing of nail varnish or nails exceeding the permitted length.

We scored the service as 3. 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 safe handling of medicines. There were processes to ensure people received the medicines that they needed.

National practice was followed in pre-assessment clinics to ensure staff had a complete medical history and list of current medicines the patient was taking. This aided decision making on any medicines changes that might be required prior to surgery. Patients were given both verbal and written information about their medicines in the outpatient clinic.

Pharmacy staff dispensed medicines prescribed in the outpatient clinic and counselled patients on any new medicines prescribed.

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

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

Paper based prescriptions were used in the outpatient department. We saw that paper based controlled drug stationary was not always appropriately tracked and monitored according to national guidance and local procedures. This meant there was a risk staff or patients could access this controlled stationary. Staff took action to rectify this during our visit.