Nuffield Health Cheltenham Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation and promoted an open, fair culture.

At our previous assessment, we rated outpatients as good. At this assessment, we rated outpatient services as 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.

We scored the service as 3. The evidence showed a good standard. 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 and their communities.

The service had a clearly defined vision that staff were aware of and understood. Posters displayed in staff areas outlined the organisation’s five ambitions. The outpatient department also held its own vision planning meeting in March 2026, where staff were encouraged to consider the future direction of the service and how this aligned with the wider organisational ambitions.

A positive and supportive culture was evident among outpatient staff. Staff were motivated to provide a high-quality patient experience and deliver person-centred care. They reported feeling able to approach their immediate line managers with any concerns. Results from the December 2025 staff survey reflected this positive environment, with a score of 8.3 (out of 10) for the statement, “I can count on my coworkers to help out when needed,” and 8.4 (out of 10) for “I have mutually supportive relationships with people where I work.”

Leaders told us recent changes to leadership and service structures had initially unsettled some staff. However, they recognised the importance of maintaining visibility and actively listening to staff in order to support the transition. Staff described the management changes as positive and reported that they felt listened to by the senior leadership team.

We scored the service as 3. The evidence showed a good standard. 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 service had a relatively new senior leadership team. The Director of Clinical Services commenced in post in February 2026, and the Registered Manager had been in position since June 2025. Within the outpatient department, there was a clear leadership structure comprising a clinical lead, 3 senior staff members, and a team of 14 staff who were supported across these senior roles.

Leaders demonstrated the necessary skills, knowledge, and experience to fulfil their responsibilities and showed a strong understanding of the services they managed. Despite the recent establishment of the senior management team, staff reported that their impact had been positive. Staff felt that leaders listened to their concerns and took appropriate action to drive improvements within the service. Overall, staff reported feeling well supported by their management team. This was reflected in the staff survey results, where the statement, “I feel I could speak to my manager about any changes happening where I work,” scored 8.2 out of 10.

There was a structured programme to support leadership development. The hospital leadership team had scheduled development days, with a comprehensive leadership development programme planned for 2026.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had policies and procedures to support a positive, open culture where staff were encouraged to speak up and felt their voices would be heard. Most staff we spoke with told us they felt confident raising concerns with their line managers.

There were 3 Freedom to Speak Up Guardians on site, supported by a regional Freedom to Speak Up lead. Staff told us they had opportunities to raise concerns, provide feedback, and share ideas for improvement. They said they received feedback in response and felt listened to.

We saw evidence that the Freedom to Speak Up arrangements were actively promoted within the service. For example, a presentation about the service was delivered to staff at the March 2026 staff forum.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders worked to create an inclusive working environment. We observed leaders being approachable and supportive to all members of staff. From the staff survey of December 2025, the service scored 8.6 out of 10 for the question ‘Where I work people of all backgrounds are valued for who they are’ and 8.3 out of 10 for the question ‘I’m satisfied with Nuffield Health’s efforts to support diversity and inclusion’.

We scored the service as 3. The evidence showed a good standard. 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.

There were clear structures, processes and systems of accountability to support the effective delivery of the outpatient service. The service operated within an established meeting framework that provided senior leaders and managers with regular opportunities to review operational performance. These were informed by quality reports on the services provided and benchmarked against the providers other locations. However, the outpatient team meeting was held regularly but suffered from poor attendance. There was an action plan to improve attendance at this meeting. This was helping to improve attendance by offering different ways to attend the meeting such as virtually from home.

A Medical Advisory Committee (MAC) met regularly to oversee patient safety, quality of care and compliance with regulatory requirements. The committee reviewed incidents, adverse events and applications for practising privileges. The chair of the MAC told us there was good consultant engagement with the committee. One consultant said that he doesn’t attend all the MAC meetings but the minutes of these meetings were shared with him.

Practising privileges, a formal process through which medical professionals are authorised to work within the organisation, were subject to regular review. We reviewed 4 practising privileges files and found that the organisation had obtained the necessary documentation to ensure that medical practitioners were safe and appropriate to practise within the service. Practising privileges were reviewed every 2 years.

The service had governance processes and policies which followed best practice. Staff were able to access these policies on the system. Staff said that new and updated policies were shared at the relevant meetings and safety huddles.

The service had a risk register, which highlighted risks to the service and any controls to mitigate them. There were 4 risks on this register and the risks were regularly reviewed to ensure they were being mitigated and to see if they could be removed if the mitigation steps were successful.

There was an emergency preparedness plan which gave details for who to contact in the event of an emergency.

We scored the service as 3. The evidence showed a good standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The hospital offered free public events where people could attend presentations on a range of health topics. These sessions could be booked through the provider’s website. The hospital held events for GPs run by the consultants. In 2025, 94 doctors attended the se events. There were public events which included orthopaedic, women and men’s health and cardiology.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service supported staff development and career progression. Apprenticeship programmes were available, and staff were encouraged and supported to enrol and complete them. For example, 2 Health care assistants were on a development programme to become a registered nurse and 1 student nurse was being supported to qualify.

The site had just started to improve the process of optimisation for patients which had been rolled out in other Nuffield Health locations. The process of optimisation aimed to identify any medical issues that could be addressed before the date of surgery had been confirmed. The service was working on a quality improvement plan dated March 2026, to increase the number of patients being optimised. The service was also looking at ways in which to staff the optimisation clinics.