Clifton Park Hospital Limited

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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.

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 have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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 reported 18 safety events or incidents in the 12 months from October 2024 to September 2025. The month with the most reported diagnostics incidents during this period was July 2025 with four. The service had the least reported incidents of the three hospital departments we assessed.

Any incidents staff raised would be reviewed at the hospital’s weekly Patient Safety Incident Review Group (PSIRG). Service incidents where any organisational learning was identified at PSIRG was escalated. Leads discussed these at the corporate monthly PSIRG meeting.

Staff knew which incidents to report, and how to report them. They used the RADAR risk reporting system. Staff received feedback and updates about incidents reported at other provider locations. This meant there was national learning from incidents.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

3. 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 had a clear referral process and system. All referrals were on an electronic system and monitored by administration staff specifically aligned to the area.

The hospital used the Picture Archiving and Communication System (PACS) which is used within the NHS. Staff could access diagnostics images from patients’ NHS records and likewise share images generated at the hospital. This meant they could provide continuity of care for patients.

The service attended the daily multidisciplinary team safety huddles. These included the head of clinical services. We saw that staff discussed serious incidents, equipment issues, patient risk, safeguarding, discharges, and staffing levels. 

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

3. 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 safeguarding adults and children’s policies and procedures in place and in date. The policies outlined the objectives, explained the terminology of various types of abuse, identified the training requirements, duties, roles and responsibilities of staff. The hospital’s safeguarding lead was available for diagnostics staff, and the on-call management team could advise on safeguarding concerns.

Staff knew how to identify and report any safeguarding concerns as per provider policy. This included raising referrals to external agencies, such as the local authority safeguarding team.

All diagnostics staff were trained in safeguarding adults and children level 2. This training included the mental capacity act and deprivation of liberty safeguards. The safeguarding lead provided relevant resources to the department, this ensured staff had easy access to key information if they had any queries.

No staff had needed to make a safeguarding referral in the 12 months before our assessment. However, we heard about shared learning from safeguarding notifications across the provider group.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them

3. 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.

Staff responded promptly to any sudden deterioration in a patient’s health. They understood how to manage people’s risks during an emergency. In the outpatients building they would call 999 to transfer to the NHS hospital if they required emergency treatment. In the main hospital building they had access to the Resident Doctor who could be called and the transfer to the NHS hospital if required.

We observed radiology teams undertaking procedures using the Local Safety Standards for Invasive Procedures (LOCSIP) guidelines.

Staff understood the risks of radiation exposure, and this was included in their pre procedure checks.

The MRI team had undertaken an evacuation simulated scenario which meant they were prepared in case of a fire or medical emergency.

We detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

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.

The design of the environment followed national guidance. Service facilities included two fixed x-ray-controlled areas; one in the main department and one in the outpatients building. The outpatients building had an MRI scanner. General radiography procedures were carried out within this department, for example, x-rays. A controlled area was in each x-ray facility / room, and a mobile x-ray was available for use.

The service was expanding capacity to meet patient demand. During our assessment the service was utilising a room in the day surgery area for guided injections. The department was having a room refurbished to provide more capacity for this service.

All service environments and waiting areas were clean, tidy, safe and well maintained.

Staff carried out safety checks of specialist equipment. Equipment met the quality assurance standards required by the Ionising Radiation Medical Exposure Regulations (IR(ME)R) regulations.

Lead aprons were checked as part of an ongoing replacement programme.

The service had enough suitable equipment to help staff safely care for patients, the equipment was replaced by the service where required. The department maintained a full log of all equipment.

We saw risk of radiation exposure notices throughout the department.

Clinical waste was disposed of correctly.

We 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.

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 need

All staff received and completed training specific to their role, including bank staff. Diagnostic staff were 100% compliant with mandatory training,

Staff told us their mandatory training was comprehensive and met the needs of patients and staff.

Managers gave all new staff a full induction tailored to their role before they started work. All staff had completed an induction programme.

The service recruited two new experienced radiographers shortly before our assessment. They were going through the onboarding process.

Consultant radiologists were employed by the local NHS Trust. We reviewed their practicing privileges which met the required employment checks.

The service had enough nursing and support staff to keep patients safe. The service had two staff in the MRI unit, and one in the outpatient’s unit which ensured that they could respond to individual needs and enabled the smooth flow of the patient list.

The manager could adjust staffing levels daily according to patient needs. The diagnostic manager reviewed the planned activity through the hospital scheduling meeting. They ensured the department had appropriately trained staff.

The service had access to a consultant radiologist if required both in and out of hours for advice when required meaning patients could have timely interventions.

A computed tomography (CT) scanner was on site monthly, this was delivered and managed by staff from the Ramsay Group. The frequency of the service provided currently met the need of patient referrals at the hospital.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The waiting areas and furnishings were visibly clean, suitable and well-maintained.

We saw cleaning audits were completed.

Cleaning records were up to date and proved all areas were cleaned regularly. Staff cleaned equipment before and after use and patient contact.

Staff followed infection control principles including the use of protective personal equipment (PPE). Staff were bare below the elbows and washed their hands between any care and treatment episodes.

The hospital had achieved Silver Accreditation in the ANTT® (Aseptic Non-Touch Technique) Patient Protection Accreditation Programme for Healthcare Providers which meant the service was protecting patients from infection during joint injections.

Cleaning materials and documents met control of substances hazardous to human health (COSHH) regulations. Spillage kits were in date and decontamination procedures were in place.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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.

Authorised staff followed systems and processes to prescribe and administer medicines safely. The service had a pharmacist on site to provide advice and ensure medications were stocked. The radiology department used limited medicines.

Staff stored and managed all medicines and prescribing documents safely. We saw they were in date and stored correctly.

Temperatures were recorded daily in areas where medicines were stored.

Resuscitation trolleys were checked daily, and all items were in date. Pharmacy also held a list of items due to expire in emergency trolleys. This ensured new stock was available before the current drugs expired.