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 has remained Good. This meant people were safe and protected from avoidable harm. However, staff mandatory training compliance was low.

The service was in breach of regulation for safe care and treatment due to low compliance in mandatroy training in some areas.

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 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had systems for reporting incidents and staff were aware of what they should report. There was a rapid, collaborative post-incident huddle (known as a SWARM) and after action reviews (AARs) following an incident. Incidents were reviewed in the weekly incident review meeting by the senior management team and Heads of Departments. Learning was cascaded to staff and actions were taken to prevent recurrence. Staff said there were Nuffield wide team meetings for shared learning and analysis of themes and trends.

Staff understood duty of candour and could explain what actions would need to be taken. We saw evidence from incident reports, duty of candour was followed.

There was a positive learning culture where staff were encouraged to raise concerns and ask questions. Staff said the senior management team were approachable and positive changes had been made.

Staff had opportunities for professional development. For example, an associate practitioner had trained to become a registered nurse, 2 nurses had trained in anaesthetics and another member of staff undertook a level 3 management course. However, some staff said the opportunities were not always available to them. The management team stated this was because there was a limited number of opportunities available each year.

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.

The service received both private and NHS referrals. The referral and pre-assessment process ensured all essential information was received to ensure patients surgery could be undertaken safely. At the time of our assessment, 97% of patients were privately funded. The service received inter provider transfers from the local NHS trust for hips, knees and complex spinal procedures. These were managed effectively by the booking team, who liaised with the NHS booking office. However, there were some delays in receiving confirmation of patient suitability from the NHS. These delays had an impact on the timeliness of arranging patient bookings.

The service provided a pre-optimisation service, pre-rehabilitation education and exercise programme and a joint pain programme to prepare people before surgery and identify any risks.

During our assessment we observed staff undertaking a World Health Organisation (WHO) checklist and stop before you block. The world health organisation surgical safety checklist is a structured tool used in operating theatres to reduce errors and improve patient safety. The stop before you block is a specific safety check used before regional anaesthesia. Compliance of the WHO checklist was audited with an average score of 98% compliance.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had up to date safeguarding policies and procedures and staff knew how to access them. Staff were trained in safeguarding, knew how to report a safeguarding concern and when to report one. All staff were trained in Level 2 and 3 Adult Safeguarding. There was a safeguarding lead within the service to support staff with concerns. Staff could also access a level 4 national safeguarding lead within the provider’s wider organisation. The service had an up to date chaperone policy.

Staff were able to describe incidents where they safeguarded people and the process they followed to report it on the incident reporting system. Staff were confident in raising concerns with management and felt supported in making decisions.

The service carried out recruitment checks. This included checks with the disclosure and barring service (DBS) for both adults and children barred lists. There was a process to review risks identified in 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 patients to manage risk and clearly communicated their treatment plan. Staff delivered safe care, ensuring patients individual needs were met.

Pre‑operative assessments were completed to screen patients’ past medical history and pre‑optimisation outcomes. This information was shared with consultants and ward teams to support safe admission. During our assessment, ward staff told us they had sufficient information to support patients during their admission and to make any necessary reasonable adjustments. For example, patients living with dementia were supported through the use of the dementia‑safe room.

We saw evidence of care plans and risk assessments being used in patient records and national early warning score (NEWS2) were completed and escalated in line with guidance. NEWS2 is the standard clinical tool used in the UK to identify, score, and respond to acute physical deterioration in patients. Staff told us NEWS2, sepsis, and pain and nausea monitoring was part of regular observations following surgery.

During our assessment we spoke to 5 patients attending for surgery. All patients told us they were well informed, had been given sufficient information, and were involved in decisions about their care. Patients were given opportunities to provide feedback at various points in their care. Staff said feedback was used in team meetings to make changes and improve the services provided.

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.

Theatre equipment was well kept and contracts were in place if equipment broke down. The service had 2 laminar flow theatres, which were designed to reduce the risk of infection. The emergency trolley was checked daily. All items were present and in date at the time of our assessment. The service was compliant with HTM 07-01 Safe management and disposal of healthcare waste.

We observed 2 temperature controlled blood fridges that were monitored remotely. Waste was disposed of appropriately and removed by porters. Sharps bins were managed safely. Chemical or substances hazardous to health were stored safely in a locked cupboard out of patient areas. There was an up to date Legionella testing report completed in March 2026, showing no Legionella was detected.

We checked equipment on the surgical ward and found all items were in date and tested for electrical safety. Fire exits were clear and corridors were free from obstruction. We observed fire procedure notices and fire extinguishers were in date.

The service was aware of and actively managing existing electrical risks within theatres, with plans for rewiring to commence in April 2026. Short‑term risk management included the use of backup generators to mitigate the impact of potential power outages. Temporary boilers were in use while the project was being delivered.

Staff reported a faulty lift which impacted transporting equipment to theatres. A temporary process was in place to mitigate moving and handling risks.

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.

The service was fully staffed with a good skill mix and bank-staff were available when required. The service had no vacancies in theatres or on the ward at the time of our assessment.

There was a resident doctor (RD) available 24 hours a day, ensuring adequate medical cover and escalation routes. On call consultants and anaesthetists were available at any time for further assistance.

The safer nursing care tool (SNCT) and national institute for health and care excellence (NICE) guidelines suggest acute wards should have a ratio of 1 nurse to no more than 8 patients. Staff levels on the ward were based on a 1 nurse to 6 patient ratio, however, the ward manager said this changed if they had a patient who required additional support. Management were supportive in arranging extra staff to ensure patients care needs were met. Rosters were planned and gaps were occasionally filled with bank staff, to ensure safe staffing levels.

Ward staff were mostly compliant with mandatory training. Data provided showed 95.5% of substantive ward staff had completed their training and 90% of bank staff. Theatre staff were at 94.5% for permanent staff and 86% for bank staff. However, there were specific areas of lower compliance across all areas particularly in paediatric basic life support, paediatric immediate life support, practical patient handling - practical, infection and prevention practical for clinical staff and immediate life support. Training was scheduled for any outstanding courses between April and June 2026. There was an action plan for all theatre staff to complete outstanding training by April 2026, monitored weekly by management. However, not all areas with low compliance were listed in the action plan.

During our assessment, we observed the ward team reallocating staff to outpatients to support with staff shortages. Staffing levels were formally reviewed, and both managers and staff confirmed there were sufficient numbers of staff available to carry out their duties safely in order to release a member of staff to outpatients.

We reviewed recruitment files and found the service was compliant with Schedule 3 of the health and social care act (HSCA). All staff had up to date enhanced disclosure and barring service (DBS) checks. Bank staff followed the same recruitment and DBS processes.

We scored the service as 2. The evidence showed some shortfalls.
The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There was an infection, prevention and control (IPC) policy and supporting guidance accessible to all staff. All areas were below target of 95% for infection and prevention, practical clinical training. Training was scheduled in April and May.

During our assessment we observed patient rooms and ward areas being cleaned. However, there were no housekeeping schedules to provide assurance cleaning of departments had been undertaken and we did not see any ‘I am clean’ stickers being used. Ward toilets had no cleaning audits and staff could not tell us when they were cleaned. Housekeeping staff told us the audits were removed due to staff shortages and being unable to do hourly cleans. Staff told us they did not follow daily cleaning schedules and said they knew what areas to clean each day. Cleaning undertaken by housekeeping was not documented. Concerns were raised verbally and no written records of these issues were maintained. Leaders told us there were cleaning schedules for each shift across all departments. However, evidence of these schedules was not available during the inspection.

The hospital followed the national cleaning standards 5 star rating system. The surgical ward and theatres appeared clean and tidy and we observed a 5 star rating on the ward and 3 star rating in theatres. Heads of departments managed the 5 star cleaning audits by reviewing all areas of the ward or theatre with housekeeping and action plans were implemented when issues were identified. Cleaning ratings for the National Cleaning Standards audit were recorded electronically, with any areas identified as not meeting cleanliness standards clearly highlighted. Deep cleaning of floors and theatres were undertaken at weekends to avoid disturbing patients and an external deep cleaning company was scheduled every 6 months for theatres.

Theatre staff undertook damp dusting throughout the department and adhered to cleaning schedules. Cleaning audits undertaken by theatre and ward staff were up to date.

Most staff adhered to IPC principles and hand hygiene audit results evidenced an overall improvement in compliance, increasing from 85% in quarter 4 of 2025, to 95% in quarter 1 of 2026. However, during our observations in theatres, we witnessed a lapse in hand hygiene practice, where a staff member turned off a tap using their hand following handwashing. There was also improper use of facemasks with one individual wearing it below their nose and no gloves were worn during cannulation of a patient. However, we saw ward staff adhering to Infection control principles including compliant handwashing and using personal protective equipment (PPE). Antibacterial hand wash was available along ward corridors as well as PPE including gloves and aprons.

The service had decontamination policies.

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 systems for the appropriate and safe handling of medicines. There were processes to ensure people received the medicines they needed.

Staff followed national guidance to ensure medicines reconciliation was completed prior to any surgical procedures. This aided decision making on any medicines changes that might be required prior to surgery and reduced the risk of cancellations and delays. We saw changes to medicines were clearly documented by staff in pre-assessment clinics to ensure clear communication between teams.

Staff had access to national and local guidance to inform decisions about medicines pre and post-surgery. For example, we saw staff were able to access local antimicrobial guidance to inform treatment decisions.

There were processes to ensure staff could access medicines, including out of hours. Medicines for use in an emergency were available, and staff knew where to locate these. Patients were given both verbal and written information about medicines in relation to their surgical procedures.

There were systems for medicines audits and medicines error report monitoring. We saw examples of changes being made to practice because of these. For example, a theme related to discharge medicines not always going home with the patient had been identified. The pharmacy worked with the ward staff to implement changes to practice to prevent this happening in the future. The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts.