Nuffield Health Cheltenham Hospital

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• 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating remains good. This meant people were safe and protected from avoidable harm, However, staff were not trained to the correct level of safeguarding children as directed by national guidance.

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. However, the service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events

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

There were no dedicated staff purely working only with children and young people due to the relatively low number of children and young people seen. However, staff in outpatients, surgery and diagnostics and imaging who looked after children and young people knew how to report incidents.

Seven incidents involving children and young people were reported in the 12 months prior to the inspection. Four of these incidents related to concerns regarding the collection of blood samples and the recording of those samples. Additional information provided following the site visit demonstrated that these incidents had been investigated, with outcomes clearly documented. Senior staff had reviewed all incidents and determined that no harm had occurred to the children or young people involved.

While learning from these incidents had been identified and recorded as shared with staff, the recurrence of incidents relating to blood sample collection and documentation indicates that improvements in practice had not yet been fully embedded. Further detail regarding these concerns is outlined in the outpatients’ report.

Staff understood their responsibilities under the duty of candour and were open, honest and transparent with people when things went wrong with their care.

Please refer to surgery, outpatients and diagnostic and imaging reports for more information.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners 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.

Referral and admission processes ensured relevant information was obtained to assess whether children and young people’s needs could be met safely. The service had defined eligibility criteria, and not all specialties accepted children and young people. Following review and risk assessment by a paediatric nurse from another provider location, some limited surgical procedures were offered to young people aged 16–17. Where required, staff followed the adult surgery pathway for young people admitted for surgery.

There were limitations in diagnostic and imaging services. Children and young people were accepted for x‑rays and scans only between the ages of 3 and 18. A dedicated radiologist was available for children and young people, and booking staff were aware of these arrangements and age restrictions.

Staff worked collaboratively with other healthcare providers to maintain continuity of safe care during admission and following discharge. There were clear procedures and pathways with the local NHS acute trust, setting out roles and responsibilities for both organisations when transfer of an unwell child or young person was required. This supported timely and safe transfers of care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always train their staff to the recommended level of safeguarding children to protect them from the risks of abuse.

Staff who provided care, treatment and support to children were only trained to level 2 safeguarding children as directed by the providers' policy. However, this is not in line with the national guidance Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff. The guidance says clinical staff working with children, young people, and/or parents/carers who could potentially contribute to assessing, planning, intervening, or reviewing the care of a child or young person must be trained to level 3.

The provider’s policy stated that staff must work more than 75% of their time with children and young people to be eligible for safeguarding children Level 3 training. At this location, the provision of services for children and young people was limited, and no individual staff member met this threshold. However, national intercollegiate guidance relates to the nature of clinical roles undertaken when providing care to children and young people, rather than the proportion of time spent delivering care.

Following the site visit, the registered manager advised us there were plans to train several senior staff to level 3 in safeguarding children. The registered manager was assured they had procedures to safeguard children and young people from the risk of abuse.

The provider had a clear safeguarding leadership structure. This included senior staff trained to Level 4 and a national safeguarding lead trained to Level 5. The Registered Manager had completed safeguarding children level 3 training. These staff were accessible for advice, escalation and clinical oversight.

There had been no safeguarding referrals to the local authority involving children and young people in the previous 12 months. Staff demonstrated awareness of their safeguarding responsibilities and understood the processes for raising concerns.

Staff were trained in learning disabilities and autism and were able to identify adults and children at risk of harm. They understood how to safeguard people from abuse, harassment and discrimination, including those with protected characteristics.

The service carried out recruitment checks, including Disclosure and Barring Service (DBS) checks against the adults’ and children’s barred lists. There was a process to review and assess any risks identified through recruitment checks.

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 with people to understand and manage risks. This supported the provision of safe care that met people’s needs and enabled them to do the things that mattered to them.

Following the assessment, the registered manager submitted evidence showing 76% of staff had completed Paediatric Basic Life Support (PBLS) training, which was below the provider’s mandatory training target of 90%. After the site visit, the registered manager provided details of additional PBLS training sessions planned to address this shortfall.

Sixty percent of staff had completed Paediatric Immediate Life Support (PILS) training, which was below the mandatory training target. Staff had received training to enable them to recognise and respond to the sudden deterioration of a child or young person.

A resuscitation trolley with paediatric equipment was in the outpatient department and was checked daily to ensure it was ready for use.

Young people aged 16 and 17 admitted for elective surgery followed the adult pathway, with their vital signs recorded and monitored using the National Early Warning Score (NEWS2) chart. NEWS2 is the standard clinical tool used in the UK to identify, score, and respond to acute physical deterioration in patients.

We scored the service as 3. The evidence showed a good standard. There was a small dedicated area for children in outpatients and for younger people undergoing surgery they were given a single occupancy room. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There was a small designated waiting area for children. This was located within a main outpatient waiting area and was segregated as much as the space would allow. Parents/guardians were required to always be present as a hot drinks machine was available in this area for patients to use.

For younger people undergoing surgery they used the single occupancy rooms on the ward. Staff told us they were able to have their parent/guardian always stay with them.

Please refer to surgery, outpatients and diagnostics and imaging reports for more information.

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

As the location provided a limited range of services for children and young people (CYP), there were no paediatric nurses or staff designated specifically to work with this group. Staff looking after children and younger people had to complete a list of competencies relating to CYP. During our site visit we were shown several completed competency booklets.

Consultants applying for practising privileges were required to complete a Nuffield Health application form. As part of the process, the hospital director met with the consultant to assess their suitability for independent practice and to confirm that their scope of practice included care and treatment for children and young people. Applications were subsequently reviewed by the Medical Advisory Committee (MAC).

Please refer to outpatient, surgery and diagnostics and imaging report for more information.

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.

There was a small designated waiting area for children in the main outpatient waiting area and the number of children and young people seen did not meet the providers threshold to have dedicated staff who provided care and treatment.

Please refer to surgery, outpatients and diagnostic and imaging reports for more details.

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.

There were no dedicated medicines for children and young people due to the limited services offered. Younger adults undergoing surgery would follow the adult surgical pathway and medicines would be adjusted to meet their specific needs

We reviewed the emergency trolleys for adults and children in the outpatient area and found daily check records fully completed, with all equipment present and in date and ready to use if an emergency was to occur.

Please refer to the surgery, outpatient and diagnostic and imaging reports for more information.