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 last assessment we rated this key question good. At this assessment the rating has remained 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.

Staff demonstrated a clear understanding of the provider’s vision and values, and how these were embedded within day-to-day practice. The service actively promoted equality and diversity, supported ongoing staff development, and fostered an open and inclusive culture in which concerns could be raised without fear of reprisal.

Staff reported feeling valued and respected within their roles. They described positive working relationships, effective teamwork, and visible, approachable leadership. Leaders supported skills development and recognised staff contributions through regular feedback and structured daily team briefings.

The service utilised benchmarking processes to monitor performance, including monthly comparisons with other Nuffield hospitals. This enabled oversight of key metrics such as adverse events, and patient satisfaction, supporting continuous improvement.

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 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 did not have dedicated leaders solely for children and young people’s (CYP) services; however, all leaders understood the service provision for CYP. Leaders described recent leadership and structural changes which had initially been unsettling for some staff. However, they demonstrated an awareness of the impact of these changes and emphasised the importance of maintaining visibility and engaging with staff to listen to and address concerns. This approach supported the service in moving forward positively.

Staff reported that they were well supported by senior leaders, who were described as visible, approachable, and responsive. Leaders demonstrated a commitment to acting on both staff and patient feedback, taking incidents seriously and responding appropriately to concerns. This approach contributed to the development and maintenance of a positive, open, and transparent culture within the service.

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

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 3 Freedom to Speak Up Guardians, supported by a regional Freedom to Speak Up lead. Staff reported that they were aware of the available channels to raise concerns, share feedback, and contribute ideas. They told us they received feedback in response and felt that their views were listened to and valued.

The provider had clear complaints processes, including escalation routes for both NHS and private patients, and encouraged early resolution of concerns, supported by relevant policies.

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 valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider maintained an up-to-date Equality, Diversity and Inclusion (EDI) policy, and leaders actively promoted an inclusive working environment. Equality of opportunity was supported through transparent access to project work, newly created roles, and external development opportunities.

The service had arrangements to prevent and address bullying and harassment. These arrangements considered the needs of staff with protected characteristics and those from marginalised groups. Reasonable adjustments were implemented where required to support staff with disabilities and ensure equitable working conditions.

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

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.

The service had clearly defined governance structures, processes, and systems of accountability to support the effective delivery of services to include children and young people. An established meeting framework, alongside monthly quality reports, enabled senior leaders to monitor performance and maintain oversight.

A Medical Advisory Committee (MAC) met regularly to oversee patient safety, quality, and regulatory compliance, including the review of incidents, adverse events, and practising privileges. There was good consultant engagement with the MAC. Processes for granting and reviewing practising privileges were effective, with documentation reviewed and privileges renewed every two years to support safe care.

Governance policies reflected best practice and were accessible to staff, who told us updates were shared through meetings and safety huddles.

A risk register was maintained and regularly reviewed, with controls to mitigate identified risks. Two risks related to children and young people (CYP) were recorded: a low-level risk regarding the possible incomplete mandatory training for some consultants which potentially could lead to more patient safety incidents, and a moderate risk concerning consultants reviewing CYP without the appropriate practising privileges. Each risk recorded on the risk register had associated mitigation actions designed to reduce the likelihood of the risk occurring and to minimise its potential impact.

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

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

Staff and leaders worked collaboratively with external stakeholders and partner agencies to support improvements in patient care and outcomes.

The service demonstrated open and proactive engagement with patients, staff, equality groups, the public, and local organisations in the planning and delivery of services. The hospital also contributed to the local community by hosting free public health events and educational presentations.

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 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.

Staff demonstrated a clear commitment to continuous learning and service improvement. The provider had structured processes to identify, review and share learning from incidents and examples of good practice, informed by both local and national themes.

Monthly quality reports supported effective oversight, enabling leaders to monitor trends, identify risks, and take timely action to reduce the likelihood of recurrence.

Staff had received training in the Patient Safety Incident Response Framework (PSIRF) and participated in regular safety huddles (SWARM), which facilitated timely incident reporting and promoted shared learning.

Staff contributions and achievements were recognised and celebrated within the service, which supported staff engagement and morale.

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