Nuffield Health Cheltenham Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard.
The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

During our assessment we reviewed 3 care records and followed 2 patients through their surgical pathway. All health assessments were completed in a timely manner and care plans met the needs of patients. Risk assessments such as Venous thromboembolism (VTE,) falls, pressure ulcer and nutritional risk assessments were documented in all care records. Care plans identified any care needs required and there was evidence of daily ward rounds including clinician review.

Staff told us patients pre-assessment records were reviewed prior to admission so staffing levels could be planned and the team could ensure any additional needs could be met. For example, patients at high risk of falls could be located in the room opposite the staff desk and additional staff could be rostered if necessary. Patients with additional needs were also discussed at the daily huddle.

Staff identified and assessed patients’ pain using recognised tools and provided pain relief in line with individuals needs. Staff told us about a patient whose pain levels could not be controlled and escalation processes were followed promptly. Staff contacted the relevant clinician for further assessment, who assisted with pain management until they returned to theatre the following day. Patients were reviewed post surgery by consultants and physiotherapists to ensure they were safe to mobilise before being discharged. Patients were involved in their discharge plans and outpatient appointments were scheduled to monitor the patients’ progress.

We scored the service as 3. The evidence showed a good standard.
The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

There was a full range of specialists available to patients within the surgical pathway, both before and after surgery. A 4 week pre rehabilitation programme was available prior to surgery providing education on diet, mental health and medicines alongside an exercise programme. The team also provided a joint pain programme supporting people with long term conditions as well as a hips and knees workshop to manage people’s expectations before surgery.

Consultants, nursing staff, pharmacists and physiotherapists worked collaboratively to support people following surgery, enabling them to safely regain mobility and strength.

Managers ensured new staff had inductions and provided annual appraisals to check competencies. At the time of our assessment, 85.1% of appraisals were completed with a target of 95%. Outstanding appraisals were due to staff absence and were planned for when staff had returned to work. Bank staff did not receive appraisals, however they had regular 1:1 with management.

Staff participated in clinical audits and benchmarking such as the National Joint Registry (NJR), patient reported outcome measures (PROMS) and the British spine registry (BSR). They also completed internal audits for VTE (Venous thromboembolism) and World Health Organisation surgical safety checklists.

We scored the service as 3. The evidence showed a good standard.
The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular, effective multidisciplinary meetings to share information and learning. Daily huddles took place, as well as ward handovers, head of department meetings and theatre huddles. We observed a daily huddle that was well attended. It had a clear purpose, highlighted any concerns and shared information to cascade to the wider team. Relevant patient information was shared to ensure optimal care. Staff said multidisciplinary meetings occurred regularly and were effective.

Healthcare professionals mainly worked well together to provide safe effective care to patients. There was good teamwork across surgical wards and theatres and across the wider hospital. However, some staff told us that there could be an atmosphere with the senior theatres team which sometimes made things challenging. This was discussed with the senior management team who were aware of and managing the situation.

While carrying out our assessment in theatres, we observed a surgeon providing a comprehensive handover and plan to the recovery nurse demonstrating effective working relationships.

We scored the service as 3. The evidence showed a good standard.
The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service provided education and exercise programmes including diet and mental health input via their pre rehabilitation plan. This prepared patients for their surgery and recovery.

There was also a range of information and advice available on the providers website including work desk ergonomic advice, fertility treatment and men’s health.

The service provided free engagement events at the hospital and Nuffield gym with topics including menopause, joint pain, spinal back pain and an evidence-based exercise programme for men post prostate cancer surgery.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The hospital participated in national clinical audits such as the National Joint Registry (NJR). This showed it was performing within the expected range for all measures of the audit for knee operations (data reviewed was up to August 2025). Hip replacement revision rates were outside of the control limits between August 2015 and August 2025, with a national average of 1.00 and the provider at 1.85. This had improved to expected limits between August 2020 and August 2025 with a national average of 1.00 and the provider at 0.90. Higher revision rates mean more patients needed further surgery, experience complications and have poorer long-term function. It should be noted however that the comorbidity of a patient can also affect the revision rate.

The service was JAG (Joint advisory group) accredited, demonstrating its formal recognition to deliver Endoscopy services. Staff undertook VTE (Venous thromboembolism) audits over a 9 month period which identified poor compliance, below 90%. Compliance was recorded at 88% in Q2 of 2025, 86% in Q3 of 2025, and 88% in Q4 of 2025. A Quality improvement plan was implemented with the objective to achieve 95% compliance within 6 months. An improvement was identified in Q1 of 2026, with compliance increasing to 94%.

There was 1 unplanned readmission for hip surgery in the past 12 months due to an infection. An investigation was undertaken and learning was identified to reduce future readmissions.

We scored the service as 3. The evidence showed a good standard.
The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The consent process was discussed during outpatient appointment and again prior to surgery. The consultant surgeon met patients prior to surgery to ensure consent had been obtained. Consent was again confirmed as part of the WHO checklist followed in theatres.

We observed a complete patient pathway from ward to recovery with good communications between all staff and patients. Consent was obtained and documented at each stage.

Staff gave an example of a patient who became agitated and refused to consent to their procedure. Staff followed protocol and the patient returned home with a relative without having surgery. Staff were confident with the consent process and enabled patients to make their own informed choices.

All staff had up to date mandatory training in the Mental Capacity Act (MCA) and deprivation of liberty safeguards (DOLs). Staff understood how to assess whether patients had capacity to make informed decisions about their care.