Clifton Park Hospital Limited

On this page

• 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 CQC looked for evidence people were protected from abuse and avoidable harm.

At our last assessment CQC 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.

Outpatient department (OPD) staff had a good reporting culture where they felt safe and encouraged to report incidents, concerns, near misses, and feedback. Leads explained this helped them improve patient safety, organisational learning, transparency and accountability, as well as staff engagement and morale.

OPD staff knew what incidents to report and how to report them. They had documented one recent patient safety event on the provider’s incident reporting system. This was a mechanical fall. There were no learning or themes from this event, as staff responded appropriately.

Staff raised concerns and reported incidents and near misses in line with the service’s policy. Managers debriefed and supported staff after severe or distressing incidents.

OPD staff understood and adhered to a professional duty of candour. They were open and transparent.

Staff received feedback from incident investigations, both internal and external to the service. Consultants told us they heard about learning from never events in theatres relating to implants. They told us senior leads were responsive, scrutinised in detail and facilitated strategic improvements. There was evidence changes had been made after feedback.

We work with people and healthcare 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.

The service worked to improve pathways and continuity of care for outpatients through joined-up clinics. For example, those attending the hand consultant also had a physiotherapist follow up appointment which had improved hand surgery patient outcomes.

Patients given wound care at the nurse-led clinic were then seen by a surgeon for aftercare as a one-stop shop. This helped outpatient’s post-operative wound healing and recovery.

Patient notes were comprehensive, and all Outpatient Department (OPD) staff could access them easily. Staff used a well embedded electronic patient records (EPR) system. Nursing and clinical staff told us the system was accessible and user friendly. They emailed patients on the system to clarify any missed appointments.

Records were stored securely. The hospital had a back up system to ensure patient records’ security.

The service completed record keeping audits. OPD completed audits of pre-operative assessment medical records twice a year. March 2025’s audit scored 98.8%. October 2025’s audit scored 100%. Both audits show good compliance to policy standards.

Outpatient admission, inclusion, and exclusion criteria were clearly defined in alignment with the hospital’s latest statement of purpose and the NHS e-Referral Service (eRS) Directory of Services. Outpatient services accepted patients based on clinical appropriateness, referral source, and their ability to safely attend appointments.

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. We make sure we share concerns quickly and appropriately.

Outpatient Department (OPD) staff received and kept up to date with training specific for their role on how to recognise and report abuse. All OPD non-registered staff completed safeguarding adults and children training to level two. Departmental compliance in both these modules was 100%.

OPD face to face safeguarding compliance was 88.9%. This was due to one of nine eligible OPD staff members having not completed the module.

All registered clinical staff had completed the face-to-face level 3 module. This meant OPD staff overall were equipped with the required knowledge and skills to identify, respond to, and escalate safeguarding concerns appropriately.

OPD staff knew how to make a safeguarding referral and who to inform if they had concerns. They had contact details for the local authority safeguarding teams.

Hospital and OPD leads were committed to ensuring all staff were thoroughly trained in identifying risks to patient safety. All staff underwent a local induction within their first month of employment. This included a comprehensive safeguarding session delivered by the hospital’s safeguarding lead. Staff covered FGM guidelines as part of their safeguarding training delivered on induction day.

OPD staff followed relevant provider and hospital adult safeguarding and chaperone policies. They ensured patients were comfortable with a male or female nurse. This helped them safeguard any adults at risk of abuse or neglect.

All eligible OPD employees had the required pre-employment checks. For example, they were disclosure and barring service (DBS) compliant and held valid checks appropriate to their role and level of patient contact.

At the time of our assessment OPD staff had reported no safeguarding incidents in the past six months.

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.

Staff responded promptly to any sudden deterioration in a patient’s health. All staff we asked knew the procedure if someone collapsed or suffered a cardiac arrest. They would start life support then call 999. Relevant staff were trained to use live-saving equipment. The Outpatient Department (OPD) staff had their own resuscitation trolley located by the waiting area in the centre of the department. We reviewed the trolley checklists and contents. No equipment or dates had been missed.

OPD staff knew about and dealt with any specific risk issues. They individually assessed all patients to ensure a safe and appropriate clinical environment. During pre-assessment, nurses explained the benefits of effective triage to patients, and the importance of decision-making based on their full medical background and information. Nursing and support staff completed appropriate risk assessments for patients.

Shift changes and handovers included all relevant key information to keep patients safe.

All staff understood the department’s eligibility criteria. They would confirm any discrepancies with their managers. For example, staff referred any outpatients who weighed over 150 kilograms back to their local NHS trust as they had no bariatric provision. The OPD manager planned to revise the department’s inclusion criteria to focus more on patient suitability.

OPD staff routinely updated risk assessments, and reviewed incidents through hospital governance meetings.

The department completed a safety scenario in July 2025. This ensured staff knew how to safely assist in the evacuation of an unwell patient from the magnetic resonance imaging (MRI) scanner. The outcome was positive with no areas for improvement.

We detect and control potential risks in the care environment. We make sure that the equipment, facilities and technology support the delivery of safe care.

The design of the environment followed national guidance. The service had now reviewed and signage and directions to the outpatient’s department was now easy to follow. This meant all visiting and first-time patients knew where to arrive and park.

Outpatient Department (OPD) staff ensured the department was a safe environment by controlling potential risks and taking several measures. For example, the department had specific risk assessments, with documented actions and a departmental risk assessment log. We reviewed the log and found no risks scored 9 or above, out of a possible 25. This meant none were considered high or extreme risk. Any OPD risks were added to the hospital risk register. Staff and leads had identified the OPD car park separately on the hospital risk register due to the surface being inappropriate for orthopaedic patients.

Staff carried out safety checks of specialist OPD equipment. Medical devices were calibrated at the point of service. For example, we saw evidence blood sugar machines were calibrated weekly, and subject to a weekly checklist. Staff conducted extra checks if the test fluid or test strips had expired or had been open over three months. Staff performed external quality controls upon receipt of new supplies. This was typically every two or three months, to maintain accuracy and reliability.

OPD staff could access funds for new equipment if they could justify there was a clinical need. For example, staff had noticed rust on the dressing trolley, so leads had ordered a replacement. The department had an improved mini computed radiography (CR) X-ray machine for digital imaging. Staff told us this was easy to access and use. They could access an ordering system for more expensive equipment.

Managers could request additional resources to ensure or promote the quality of care and treatment. For example, they had previously asked for a new echocardiogram (ECG) machine. Quotes were sourced through their stores department, and hospital director approval was granted.

OPD staff followed the corporate fire safety manual. This ensured they worked in a safe environment. All staff undertook e-learning and face to face fire safety training annually. Fire safety training was included in their site induction and refreshed yearly. Fire drills were completed twice a year to ensure compliance with the fire safety processes detailed in the manual. We saw the latest fire drill was in July 2025. It found the premises were compliant. Moreover, an external provider audited compliance through an annual fire risk assessment. Audit actions were monitored through the related action plan.

The hospital had two fire incident officers onsite at all times. Staff we asked knew fire procedures and how to direct patients and other visitors to safely exit the premises.

The service had enough suitable equipment to help staff safely care for patients. Housekeeping staff shared examples of stocktaking and storage improvements after they raised issues with the head of department.

Staff disposed of clinical waste safely. We saw OPD’s latest sharp bins audit from April 2025. This showed the department was 95.83% compliant. Two sharp bins did not have a temporary closure in place between use. The audit summary showed sharps containers were not assembled properly. Staff took immediate actions to rectify both areas for improvement.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development. They work together effectively to provide safe care that meets people’s individual needs.

Staff received and completed training specific to their role, including bank staff. Outpatient Department (OPD) staff completed mandatory e-learning annually. Staff we asked had completed all their yearly mandatory and refresher training . Outpatients mandatory training compliance was 100%.

Most modules were e-learning online. During our assessment a new healthcare assistant was completing e-learning modules. Practical training modules had good availability. Outpatients’ compliance for face-to-face training was 90.1%. This met the provider’s target. Nine OPD staff, including some new starters were booked onto but had not completed the face-to-face intermediate life support (ILS) module.

Staff told us their mandatory training was comprehensive and met the needs of patients and staff. They compared the provider’s training favourably with other hospitals where they had worked. Leads monitored staff training records through the provider’s learning management system. They alerted staff when they needed to update their training.

The service had enough nursing and support staff to keep outpatients safe. We saw OPD staff rotas for the three months from July to September 2025. All were fully staffed, except for one absent support staff member. The pre-operative assessment (POA) team registered nurse support was integrated into the rota to bolster clinical capacity. This meant the number of nurses and HCAs matched those planned.

The manager could adjust staffing levels daily according to patient needs. They used a staffing tool which gave them an overview of safe staffing levels. These were one or two staff nurses and one HCA per clinic to support consultants. A dedicated staff member oversaw each clinic. During our assessment the manager had six OPD staff nurses with pre-assessment training they could use for extra clinics. Several clinical and some support staff worked cross-site in collaboration with the local acute trust.

All HCAs in the OPD completed a competency booklet utilising a clinical skills website to support their learning. We observed HCAs were specialty trained and upskilled. For example, in splinting, casting and many other post-operative treatments. This helped provide structural support to patients alongside their physiotherapy.

Managers gave all new staff a full induction tailored to their role before they started working in the department. OPD leads gave all new starters a corporate induction booklet. Nursing and healthcare assistant staff also attended a local induction session. This gave them essential information about departmental procedures, key contacts, and department-specific expectations. This local induction was supported by resources such as the provider’s updated local induction presentation. It ensured new team members were well-equipped to deliver high standards of care from their first day.

The service had a low vacancy and turnover rate.

Managers could access extra nursing and support staff. The department manager would block book agency nursing staff when necessary, such as during August’s peak annual leave. The provider had a contracted workforce solutions team who approached agency staff. The manager could also access a fully trained and very embedded bank team from the provider hospital group. Bank staff we spoke to were offered regular shifts. They knew the consultants in clinic well and had gained good working relations.

Managers supported all staff to develop through yearly appraisals of their work. They supported staff’s learning and development needs. We saw ODP’s professional development review compliance was up to date. They offered staff mid-term review meetings to discuss any issues.

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

Clinical areas were clean, tidy and uncluttered with suitable and well-maintained furnishings. The provider now ensured Outpatient Department (OPD) staff monitored and documented their use of spill kits. For example, staff carried out daily, weekly and monthly checks of the OPD first floor resuscitation trolley. Leads audited their checks.

Housekeeping staff who cleaned the department had chemical spill training after our last inspection. They found this helpful, as no serious chemicals were stored in this building, only in theatres. They did not leave their cleaning trolley unattended.

The service had an infection prevention control (IPC) lead and link senior staff nurse. They kept up to date with latest infection rates and related issues, whilst undertaking audits. Leads updated the hospital’s legionella remedial risk assessment and action plan in May 2025. Healthcare assistants (HCAs) maintained a Methicillin-resistant Staphylococcus aureus (MRSA) list to check patients were not susceptible to infection both pre and post-operatively. MRSA is a type of bacteria resistant to many antibiotics. This makes it hard to treat.

Cleaning records were up to date and proved all areas were cleaned regularly. We found no gaps or errors in OPD deep clean records from July to September 2025. Staff typically cleaned all areas daily, with additional spot cleaning as needed throughout the day. They used routine daily cleaning protocols, focusing on high-touch surfaces such as chairs, door handles, and reception counters.

Staff carried out enhanced cleaning protocols within OPD treatment rooms. These were designated as higher priority than consulting rooms and waiting areas, due to the moderate-risk procedures performed. For example, wound care, dressing changes, and the administration of injections. Staff documented and monitored all cleaning activities to ensure compliance with healthcare hygiene standards.

Staff followed infection control principles including the use of protective personal equipment (PPE). We observed OPD nurses and support staff using suitable PPE for patient treatments. Staff adhered to the aseptic non-touch technique (ANTT) for any patients with surgical wounds or skin damage. ANTT is a framework used to standardise and improve clinical standards during invasive procedures. The IPC lead as link nurse trained all OPD nurses in ANTT. The department was ANTT silver accredited.

Staff cleaned equipment after patient contact. They labelled equipment to show when it was last cleaned. All decontamination of any devices used in OPD was completed onsite.

We saw cleaning materials and documents met control of substances hazardous to human health (COSHH) regulations. These UK regulations are designed to protect workers from health risks associated with hazardous substances. They were stored safely and securely in a locked cupboard. Door pin codes were used to access cleaning room materials. Cleaning staff only shared the pin when the main OPD cleaner was on leave.

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.

Staff followed systems and processes to prescribe and administer medicines safely. The department’s most used medication was local anaesthetic steroid injections for orthopaedic patients. Administering staff had two types of varying strength. The clinic consultant assessed which the patient required, then prescribed and administered. We saw nursing staff checked patient’s identification and allergy status before proceeding.

Staff provided advice to patients and carers about their medicines. For example, staff gave outpatients two leaflets ; one on medicines and another on unlicensed and “off-label” medicines. Staff completed a form for the off-licence medicines including their dosage and lot number.

Staff reviewed each patient’s medicines regularly. Outpatient Department (OPD) staff could access a lead pharmacist onsite. They completed ambient temperature checks for medicines throughout the department.

Staff completed medicine records accurately and kept them up to date. OPD nurses inputted all patient’s medicine details onto an integrated care pathway which sat in the provider’s electronic patient records (EPR) system. They initially used paper anaesthetic and drug charts during any procedures before uploading.

Staff checked patients had the correct medicines early in their pathway, and when they moved between services. Staff noted any private prescriptions patients had on yellow slips then scanned onto their EPR. Consultants could advise and prescribe advanced medications management for patients experiencing pain through their GP. This could entail injection therapies and various interventions to manage pain as needed.

Staff stored and managed all medicines and prescribing documents safely. Patients who struggled to manage, had reduced or lacked capacity could access medications on time through Nomad packs. Consultants could also ask the pharmacist onsite to FP10 outpatient prescriptions. These were specific forms used by healthcare professionals to prescribe medications to patients in primary care.

Staff learned from patient safety alerts and incidents to improve practice.