Clifton Park Hospital Limited

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment CQC rated this key question good. At this assessment the rating remained good. This meant people’s needs were met through good organisation and delivery.

We looked for evidence people and communities were always at the centre of how care was planned and delivered. We checked the health and care needs of people and communities were understood, and they were actively involved in planning care which met these needs. We also looked for evidence people could access care in ways which met their personal circumstances and protected equality characteristics.

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 make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

The Outpatient Department (OPD) environment and service was designed to meet the needs of patients living with dementia. Staff took a structured approach to identifying and supporting patients with dementia, mental health conditions, or learning disabilities from the point of referral. Staff flagged specific needs early where possible during the referral process to ensure appropriate planning and support.

They offered patients tailored pre-assessment pathways. These included initial needs identification, enhanced staff support, weekly multidisciplinary team to discuss care and treatment hospital familiarisation visits and admission preparation. This proactive and person-centred approach helped staff reduce distress, improve patient outcomes, and ensure compliance with equality and safeguarding standards.

Hospital and department leads were committed to inclusive care. They had policies for patients who needed additional support to access information and services. Staff identified and documented any communication and physical support needs patients had. They used the patient records database to flag alerts, and electronic patient records to flag special requirements.

Managers ensured staff, patients, loved ones and carers could get help from interpreters when needed. Staff could provide interpreter services, large print or braille materials. They also supported accessibility for patients through a hearing loop system. This was available at reception to support patients with hearing aids. Signage was in place, and staff were encouraged to proactively offer this support.

Staff met the information and communication needs of patients with a disability or sensory loss. The OPD had specific pathways in place for patients with disabilities, dementia, mental health conditions, and sensory impairments. Staff had completed their Oliver McGowan statutory training for learning disability and autism.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

The service’s clinics ran on time and did not keep patients waiting. During our two-day assessment, OPD clinics never ran over 10 minutes behind.

Patients in the department were prompted to remind receptionists if they had been waiting over 30 minutes. Staff displayed magnetic strip cards on a board behind reception if pre-assessment clinics ran 30, 45 or 60 minutes late to inform patients. If nurses were delayed with a more complex patient, they could ask the pre-assessment healthcare assistants (HCA) to start the next patient’s echocardiogram (ECG), blood tests, or swabs. Staff retained 15 minute overlap, so patients were less impacted.

The OPD followed a structured protocol for managing clinic delays. This approach prioritised transparency, timely communication, and patient comfort. For example, staff monitored patient’s wait times throughout the day. If a patient had been waiting for over 30 minutes, staff initiated the delay protocol. Staff informed patients of delays over 30 minutes. They provided verbal updates, including an estimated wait time where possible, to help patients manage expectations. Staff updated the clinic board to reflect the delay next to the affected consultant’s clinic. Delay indicators were noted as 30, 45 or 60 minutes late or more.

Staff made these updates promptly and clearly. This ensured visibility and understanding for all patients in the waiting area. If necessary, appointments were rescheduled and refreshments offered.

We heard one or two consultant clinics could run a bit late. For example, the spinal consultant often needed extra time with their patients, as their specialty area was complex and more unpredictable. Other patients understood they would also get more consultant time to explain and cover everything. Reception staff would ring patients later on the list to adjust times or reschedule if needed.

The OPD team had an email service for patients who phoned frequently with wound care, pain management or post-operative issues. They dealt with enquiries and passed on information to the relevant clinic staff. For example, if a patient had forgotten to inform staff of medications they were on.

The pre-assessment team picked up any related enquiries around medicines, when to start drinks, and coughs or colds. Staff rang back patients as soon as possible after being advised by reception staff.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.

Staff talked with patients, families and carers in a way they could understand. They used communication aids where necessary. For example, an Outpatient Department (OPD) staff member had designed a leaflet for patients with relevant information after their local anaesthetic steroid injections. This was the most common type of local anaesthetic staff administered. Other patient information leaflets stored online could be tailored or personalised to meet people’s needs.

The department had information for patients on monitoring surgical wounds for infection as part of the national programme in hospitals. This included information about the UK Health Security Agency in different languages.

The service adhered to information governance principles. OPD had a data protection officer who monitored their Date Protection Information Security. Staff completed relevant mandatory governance training as part of their induction.

We make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. We involve people in decisions about their care and tell them what's changed as a result.

Eight outpatients (including some complex) and their loved ones we spoke with were very positive, satisfied and complimentary about the service and again felt nothing could be improved.

Patients gave positive feedback about the service. Leads told us feedback gained was valuable. We saw examples of recent thank you cards and positive online reviews.

Outpatient Department staff collected patient feedback through digital surveys and the NHS Friends and Family Test (FFT) results. This informed service improvements such as extended clinic hours and improved signage. We saw a summary of the department’s survey feedback for the last 12 months. Results remained consistently high, with multiple months achieving 100% satisfaction. Their latest FFT results from September 2025 gained 100% positive responses. Leads felt this consistently reflected their commitment to delivering care with kindness, compassion, and dignity.

Patient’s qualitative comments offered valuable insight into their positive experience. FFT feedback showed outpatients felt respected, listened to, and treated with kindness. Feedback consistently highlighted compassionate interactions and care delivered with dignity. Leads used this insight to celebrate good practice and make targeted improvements. They ensured these values remained central to outpatient services.

Staff could give examples of how they used patient feedback to improve daily practice. The service and quality improvement manager had used feedback from patients with a sensory impairment to improve accessibility through responsive actions. For example, large-text versions of patient letters as well as future communications and correspondence.

Patients and their families could give service feedback. Staff supported them to do this. The OPD manager used their experience from another provider hospital’s poor attendance to improve formal patient advocacy across the service.

At the time of our assessment, OPD had held two patient participation groups (PPGs). These aimed to support ongoing service improvement. We saw promotional PPG cards patients could pick up in waiting areas.

However, these groups had limited input from the hospital's non-orthopaedic specialities. Staff had struggled to find patient representatives from these.

We ensure everyone can access the care, support and treatment they need when they need it.

Clinics were accessible and adaptable to meet patient needs. We reviewed the OPD’s referral to treatment times for the six months from March to August 2025. During this period the average wait times in weeks had reduced by 5.7. This meant patients’ access to consultations and appointments had improved.

The OPD complied with the Accessible Information Standard and Equality Act 2010. Processes were in place to support compliance. Staff ensured equitable access for patients with language needs. They identified any interpreter needs patients had during referral, registration, or through the patient health questionnaire. Staff recorded these in the patient record. This triggered an automatic application to all current and future referrals through an interpreter icon on clinic lists, and standardised booking of face-to-face interpreters.

Staff flagged any accessibility needs patients raised in health questionnaires. They reviewed these prior to appointments. The service had plans underway to create an accessibility landing page and upload screen-reader-friendly PDFs.

OPD leads supported wider access to treatment within the local healthcare community and in collaboration with the local acute trust, hospital and provider. They had implemented a pioneering insourcing initiative to support the delivery of the local trust’s elective waiting list through the development of an onsite elective hub. This provided local patients with equitable, timely access to NHS orthopaedic care. This initiative was nominated for a health service award.

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor their care, support and treatment in response to this.

Consultants told us their specialist clinics and theatre utilisation rates were good. They reflected their team’s efficiency and consistency. The very few cancellations and did not attends (DNAs) they had were in younger patients with acute issues.

The provider’s waiting list and access policy ensured outpatients had transparent and equitable access to NHS treatment. Leads proactively oversaw the elective waiting list. They applied established protocols for DNA management, active monitoring, and inter-provider transfers in accordance with organisational policy.

Managers monitored and took action to minimise missed appointments. They ensured patients who did not attend appointments were contacted. Staff followed the hospital’s DNA process for patients who DNA their outpatient appointment. Leads knew the most common reasons given anecdotally.

However, the OPD did not formally capture reasons for missed appointment DNAs. The department’s DNA rate had slightly increased. They had 5 DNAs out of 283 referrals in June 2025 (1.8%) and 7 DNAs out of 241 referrals in September 2025 (2.9%).

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make informed decisions about their care.