The Ridgeway 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

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

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.

The service did not always make sure patient’s care and treatment were effective because they did not always check and discuss patient’s health, care and wellbeing needs with them.

Staff mostly took account of patients’ preferences and wishes if their condition deteriorated. However, we reviewed 4 patient records and found that the patients’ wishes regarding pulmonary cardio resuscitation were not clearly documented in 2 of the patient records. We raised this with service leaders who were confident that decisions were recorded where necessary and if no decision was recorded, all staff would assume patients’ wishes were to be treated and resuscitated in the event of a life-threatening deterioration or surgical complication. We requested documentation audits to corroborate our findings; however, we did not receive any audits concerning documentation.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe.

Staff assessed patients’ communication needs and ensured additional support was provided to ensure effective communication that met the patient's needs.

Staff assessed patients’ pain and used recognised tools to do so. Staff gave pain relief in line with individual needs and best practice and assessed how effective this was. Patients’ pain was addressed before they left the operating theatre. Patients told us they received pain relief soon after requesting it. They felt their pain was well managed. Service leaders carried out a ‘pain management audit’ which showed 96% against 18 measures in the quarterly audit (January to April 2026) and was a significant improvement against the previous quarterly audit (September – December 2025) which had showed 79% compliance.

The service usually planned and delivered patient’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

The service used clinical assessment (risk assessments) and care planning tools based on national guidance. For example, staff carried out preadmission assessments for all patients having surgical procedures to confirm the service could meet their clinical needs safely in line with guidance from The Royal College of Anaesthetists: Preoperative Assessment and Optimisation for Adult Surgery (2021). Staff used the provider’s pre-assessment policy and standardised documentation to review key medical conditions, infection risks, and other factors such as mobility. In addition, this included a ‘clinical frailty’ assessment for all patients over 65 years.

Staff followed up-to-date policies and standard operating procedures (SOPs) to plan and deliver high quality care according to best practice and national guidance. Policies and SOPs were mostly regularly reviewed and were referenced to ensure they were aligned to current national guidance. However, in the operating department, we saw 1 guidance document that should have been reviewed in June 2025. There were systems to communicate changes in guidance through meetings and safety briefings.

Staff completed patients’ fluid and nutrition charts where needed. The information was used to inform care planning and delivery. Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition. Patients requiring special diets for clinical reasons, were assessed and advice given.

The service usually worked well across teams and services to support patient. Staff made sure patient only needed to tell their story once by sharing their assessment of needs when patient moved between different services.

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Staff reported healthy working relations across staff groups including between medical and nursing teams. We saw and heard examples of effective team working which was based on mutual respect and trust. We observed the morning huddle in the theatre department, the inpatient ward, and the daily "Comms Cell" meeting, which brought together representatives from a range of departments, including catering, estates, pharmacy, administrative staff, and clinical teams. During all meetings observed, staff were engaged, actively contributed to discussions, and felt able to speak openly. There was clear evidence of positive working relationships, with good rapport and mutual respect demonstrated between team members across departments.

Plans for discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. Discharges were planned at an early stage to ensure they were safe and appropriate for the person’s needs.

Patient records demonstrated effective multidisciplinary working and information sharing to support a coordinated and consistent approach to care and treatment.

The service generally supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

The service supported people to manage their health and wellbeing so they could maximise their independence, choice and control. Staff supported them to live healthier lives and where possible, reduce their future needs for care and support.

Patients undergoing elective surgery had access to information about their condition, treatment options and how to prepare for their procedure. Staff supported patients to optimise their health before surgery and discussed lifestyle changes that could improve surgical outcomes and recovery. For example, physiotherapists completed pre-operative assessments when required, enabling early intervention and support. Patients were also provided with information and exercise programmes to aid recovery following a range of surgical procedures, including gynaecological, hip and knee surgery.

The service monitored patient’s care and treatment to continuously improve it. Staff ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of patient themselves.

Staff monitored the effectiveness of care and treatment through audit and benchmarking to compare with other similar services. The service used the findings to make improvements and achieved good outcomes for patients.

The service participated in relevant national clinical audits, including the National Joint Registry (NJR) and the National Breast Registry. Information was submitted with consent from patients and was used to monitor safety, performance and outcomes and enabled benchmarking different surgical procedures, surgeons and hospitals. Data showed the service was 100% complaint with submitting data between 1 June 2025 and 31 May 2026. This meant the service has achieved NJR Quality Data and Provider Gold Award in 2025.

The service reported information to the Private Healthcare Information Network (PHIN). Intelligence reports were reviewed by service leaders. These reports contained data patient activity volumes, length of stay, never events, ‘patient reported outcome measures’, and infections. We reviewed information submitted between January and December 2025 and found there had been no infections reported and feedback through ‘patient reported outcome measures were slightly above the national average for hip replacements and slightly below the national average for knee replacements with a response rate above the national average. Data was also benchmarked against other Circle Health Group hospitals and showed similar results between May 2023 and May 2026.

The service had a low number of readmissions for patients having surgery. Data showed there were 4 patients readmitted following surgery between May 2025 and April 2026. Similarly, the return to theatre rate was also low with 6 cases reported between May 2025 and April 2026.

Improvements had been made because of accreditation reviews to ensure care and treatment was in line with national guidance and standards. For example, the service had taken part in an accreditation audit by designated auditors authorised on behalf of the Association for Perioperative Practice. We reviewed the report from the final visit in July 2025 which looked at specific criteria that had not met expectations in a previous peer-review visit in November 2023. Data included within the report showed the improvements the service had made to be fully compliant. The service achieved Aseptic Non-Touch Technique (ANTT) Gold Accreditation in August 2023 and was preparing for its re-accreditation review in August 2026.

The provider considered health inequalities and took steps to ensure that outcomes across people with protected characteristics were in line with the wider community.

The service monitored and reacted to avoidable deaths and harms. Mortality and morbidity meetings were held every quarter. Mortality reviews followed a framework which was aligned to national guidance and included involvement and engagement with bereaved families. Learning from these meetings was shared with the aim of making improvements and included learning from other locations managed by the Circle Health Group.

Unexpected delays to treatment were managed effectively by making alternative arrangements where this was needed.

The service told patient about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Consent for surgery was sought by the most appropriate doctor and included discussion about the benefits, potential complications, the risks and alternative options. Staff followed the services policies related to consent, including when obtaining consent from patients receiving cosmetic surgery to ensure all patients were given a ‘cooling off’ period before going ahead with the intended surgery in line with legal regulation and professional standards.

Patient consent was checked at various points before they went to the operating room and immediately prior to surgery. Service leaders carried out consent audits completed and outcomes shared with staff. Data showed 100% compliance between May 2025 and April 2026.

We observed staff obtaining verbal consent before delivering care and treatment. Patients were actively involved in decision-making about their care ensuring their preferences and choices were respected.

Where specific requests had been made by patients, for a same sex health care professional or theatre team, this was discussed and provided whenever possible. Chaperones were provided if requested. Service leaders carried out a ‘chaperone audit’ which showed 94% or above compliance.

Interpreters were used to support patients to give informed consent, including for British Sign Language and face to face interpreting when necessary.