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 CQC did not rate effective. At this assessment the rating was good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence people and communities had the best possible outcomes because their needs were assessed. We checked 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 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.

Staff identified and assessed patient’s pain using recognised tools. They gave pain relief in line with individual needs and best practice. Consultants had created a limited liability partnership (LLP) body to offer a private pain service in the department. The hospital had a separate contract to work in collaboration with the local NHS trust. This was partly to provide NHS pain treatments to address their long waiting lists and high rate of did not attend (DNA) appointments. We spoke to the clinical lead who used a range of tools and resources to assess, and monitor referred patients’ level of pain.

Patients could access pain support soon after requesting it. They could access same week appointments for the one day a week new pain service.

During our assessment the service was trialing a roll out of Saturday pre-assessment clinics for selected, lower risk patients to meet local demand. Managers were also planning to introduce evening and weekend out of hours phone assessments for younger patient demographics.

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

Staff followed up to date policies to plan and deliver high-quality care according to best practice and national guidance. For example, Outpatient Department access policy was governed by the principles outlined in the provider’s waiting list and access policy. This ensured prioritisation based on clinical need and patient rights under the NHS Constitution.

Managers and clinical specialists identified changes to national guidance. The access policy integrated national guidance including NHS England’s revised model and Evidence-Based Interventions (EBI).

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

Staff held regular and effective multidisciplinary team (MDT) meetings to discuss patients and improve their care. The Outpatient Department (OPD) manager attended the hospital’s daily MDT safety huddle. They summarised all OPD consultant’s clinic lists including pre-assessment and learning needs for any new staff. OPD staff placed any relevant preoperative information and MDT outcomes directly onto patients’ medicals records within their records system.

Consultants, nurses and healthcare staff worked together to care for patients, and provided effective clinical care. Preoperative assessment (POA) staff assessed all outpatients against the hospital admission criteria. They assessed if a referral was escalated to an anaesthetist for further review. Based on the outcome, the patient may be referred to the hospital’s MDT. This comprised ward nurses, preoperative assessment nurses, physiotherapist, head of clinical services and theatre staff. The MDT considered if patients could be treated safely and all appropriate services provided.

Consultants could make appropriate referrals to other teams if patients required additional support. Some consultants held substantive posts at the local NHS hospital. Service level agreements (SLAs) were in place to second them and use the department’s rooms and facilities for their non-seconded work. Consultants were complimentary about their working relations with OPD staff.

Nursing and support staff were flexible and could mostly cover each other’s clinics. The department had daily nurse-led clinics to see and treat outpatient’s wound care.

OPD staff operated in line with the hospital’s outpatient operational policy. The department demonstrated compliance with relevant national guidance through a structured approach across five key areas: safe, effective, caring, responsive, and well-led care. Staff worked in line with up-to-date policies produced by our corporate teams. These were aligned with the National Institute for Health and Care Excellence (NICE) and NHS England standards. This included infection prevention protocols and safeguarding procedures.

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

Staff assessed patient health at every appointment. They provided support for any individual needs. Clinical staff working in outpatients and pre-operative assessment (POA) were key to the hospital’s patient reported outcome measures (PROMs) programme. The department achieved high response rates. They encouraged patients to complete their pre-operative PROM questionnaires at initial consultation, or before they attend POA.

The service had relevant information promoting healthy lifestyles and patient support in waiting and reception areas. Staff gave patients information leaflets with a QR code or web link to access for completion. They engaged with outpatients to actively encourage their participation.

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

Outpatient Department (OPD) staff monitored their effectiveness of care and treatment. They were reminded to complete audits at the hospital’s daily multidisciplinary safety huddle. Managers and staff participated in a monthly audit programme.

The department’s cleanliness was checked by managers and an external compliance team. Scores and trends were reviewed and discussed in accordance with the 50 steps of cleaning. During our assessment, staff told us OPD cleanliness performance was stable.

We reviewed 50 steps cleaning audits in the OPD for the past 12 months. During this period staff completed weekly inspections. The average audit result was 97.8%.

We saw OPD’s performance dashboard as of 17 October 2025. This covered the previous 12 months. The majority of appointments in the department were trauma and orthopaedics. The top three type of appointments booked were for follow up, post-operative follow up or pre-admission assessment.

The department contributed to the NHS’s PROMs for hip replacement procedures. Their pre-operative participation and linkage rates were higher than national benchmarks. OPD’s pre- and post-operative returns was significantly higher than national benchmarks. Their response rate was 100%.

Staff used audit findings to make improvements and achieve good outcomes for patients. The OPD was incorporated into the hospital’s monthly health and safety audit calendar. Staff conducted Tendable audits as part of their clinical audit programme. This included monthly cleaning and hand washing audits. There were actions arising from the audits. The actions were designated to a responsible staff lead to address any areas of non-compliance.

Clinical staff conducted clinical audits quarterly. For example, adherence to wound care pathways. They implemented action plans where needed. Their latest wound care audit from August 2025 scored 88.2%. Areas of non-compliance related to staff not documenting the size of the wound. Audit leads fed this back to staff at the time of the audit.

Audit actions relevant to the OPD included ensuring all staff had attended fire safety training with the new presentation. Also ensuring the external fire risk assessment action plan from August 2025 was completed, and all OPD staff were compliant with hand hygiene.

The OPD contributed to hospital audits in accordance with the corporate clinical audit programme.

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

Outpatient Department (OPD) staff clearly recorded consent in patient notes. They gained written consent from outpatients when needed.

Patient notes were comprehensive and stored securely on their EPR system. We saw examples of written patient notes where consent was gained for a proposed surgical procedure in the OPD department by a medical staff member.

Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005. When people lacked the mental capacity to make a decision, staff ensured best interests decisions were made in accordance with legislation.