Clifton Park Hospital Limited

On this page

• 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 effective as good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this. 

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

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.

The service had a comprehensive guideline on the patients who could be treated at the hospital, these were people with low medical risks.

When concerns regarding the initial imaging was identified there was a clear procedure for escalation to ensure patients were reviewed quickly by the referring clinician.

Patient notes were comprehensive, and all staff could access them easily. We saw staff fully completed electronic patient records (EPRs) and pre-procedure risk assessments. The EPR system was well-embedded. Clear signs were displayed throughout the department warning against the risks of exposure to pregnant women. Staff’s MRI pre-assessments checks were comprehensive and adhered to (IR(ME)R) standards.

Records were stored securely. The hospital had a back up system to ensure patient records’ security. A translation service was available where required.

We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

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.

The team had access to the full range of specialists required to meet the needs of patients in the service.

Staff participated in audit and quality improvement work. They had undertaken quality improvement and had developed a pain service.

The department had audit systems in place to facilitate regular audits against IRM(ER) and Ionising Radiations Regulations (IRR) standards and requirements, along with an annual physical audit carried out by the Radiation Protection Advisors and Medical Physics Experts.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. There was access to a consultant for advice when required.

The updated IRM(ER)standards were not in the policy and procedures that were available to staff on site, these were being updated at the group level. These were agreed and signed off at the national group meeting whilst we were on site. Although the guidelines were not within the current policy they had been reviewed to ensure that current practice was in place.

There were regular minuted team meetings.

The percentage of staff that had had an appraisal in the last 12 months was 75% for clinical staff and 33% for other staff, however this only equated to 3 staff not yet having received an appraisal.

Training opportunities to develop the service were in place, the service had given extra training to staff to deliver the pain imaging service.

We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

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.

The radiology information system (RIS) integrated with other systems such as PACS (Picture Archiving and Communication System) and HIS (Hospital Information System and the NHS.

The diagnostics manager attended the hospital morning huddles and disseminated any information to the team; they also attended the scheduling meeting to ensure they had the staff to support clinics and theatre lists.

We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

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 had undertaken work to reduce waiting times. There was health promotion notice boards within the hospital. The new pain service was in response to the local population requirements.

Patients told us they did not have to wait long for appointments which meant they were able to have a prompt treatment plan put in place.

We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

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, and that they met both clinical expectations and the expectations of people themselves.

Staff had completed training in recognising the deteriorating patient and had undergone simulated training as a key element of patient safety and improving patient outcomes.

The service completed record keeping audits. Radiologist reports were audited quarterly by a contracted auditor. This ensured they met the Royal College of Radiologists reporting standards. Any actions were shared with the radiologist

We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

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.

Staff had the appropriate skills and knowledge to seek consent from patients. Staff were clear on how they sought verbal informed consent and written consent before providing care or treatment. The consultant radiologists sought consent from patients undergoing invasive procedure during the initial consultation and again on the day of the procedure. 

Staff had received training in consent and explained procedures; consent was documented. Consent was audited and where patients were requiring x-ray, there was evidence in the consent that the risks of receiving radiation had been discussed, information leaflets were provided.

There were posters throughout the department outlining radiation risks.