Clifton Park Hospital Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means CQC looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and our communities in order to meet these.

OPD staff understood and shared the hospital’s clear vision and values. The vision was achieved through their strategy on a page which outlined four strategic pillars. Each pillar included short and long-term goals, key performance indicators, and enablers to ensure measurable progress and accountability.

The manager understood their strategic priorities and how they related to wider hospital services. During our assessment their priority was working towards the getting it right first time (GIRFT) model. They attended GIRFT panel meetings. . The manager’s focus was on ensuring referred patients were suitable for surgery and all risks were mitigated.

The OPD manager had some examples of early service development plans. Two examples were patient participation groups and a private pain service. They were also aware of scope and equipment for future OPD clinics, such as for patients with carpal tunnel syndrome.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support. Leaders embody the culture and values of our workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty.

The OPD manager clearly demonstrated oversight, dedication and focus of all clinical and non-clinical governance processes, arrangements and issues within their department. Staff told us leaders and especially their manager was highly visible. They would always make themselves available when required.

The manager was well supported and maintained good cross-site relations with the head of clinical services (HCS) and senior leadership team (SLT). The HCS as clinical lead, and operational manager visited the department often. The OPD staff team appreciated seeing SLT members. Senior and hospital leads were aware of the latest OPD issues. For example, they prompted regional provider teams or linked staff to be more responsive to the OPD manager.

The OPD manager attended all relevant meetings. This included a short weekly patient safety incident response group (PSIRG) after the huddle to discuss any issues. For example, if complex patients were suitable to attend clinics.

We foster a positive culture where people feel they can speak up and their voice will be heard.

Staff told us the service had a positive, friendly and inclusive culture. All OPD staff we spoke were positive about working for the hospital and felt respected, appreciated and well supported by managers and teams to raise any suggestions or concerns. Staff we asked had no areas for improvement when we asked what would make their job easier.

Staff adhered to the provider’s Speak up for Safety initiative. They could access support from occupational health and an external counselling service if needed. Posters signposted staff to well being organisations and resources.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Senior leads and managers reminded staff to complete the yearly staff survey.

However, one staff member was less positive about the survey, and said the questions were too generalised and did not apply to their role.

Staff could submit ideas and nominate colleagues for different awards. They were given the opportunity to have a voice through ‘you said, we did’.

We found many staff in the department were long-term employees of the provider. They praised the senior staff’s responsiveness, accessible staff well being facilities, social events and activities and the hospital’s open culture.

Staff could access a wellness care first 24 phone helpline. Staff working over 30 hours a week could access private medical insurance cover. We saw posters around the department to raise staff awareness of extracurricular events.

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

Nursing and clinical staff would apply relevant clinical codes and outcomes onto the EPR system. This data was reported and captured through clinical dashboards for review by hospital governance leads.

OPD managers and clinical staff used a system for reporting clinical governance issues. This could cover patient infections, booking errors, staff member falls, or medicines management issues. Staff could filter these reports to see themes and trends of any patient-related issues. Leads reviewed reports to inform governance discussions. OPD staff attended weekly patient safety meetings to promptly cover any issues.

The OPD manager did not attend the hospital’s medical advisory committee (MAC). However, they had clinical representation through the HCS and would review minutes and updates. For example, the department’s unlicensed medication for local anesthetic steroid injection leaflet had been signed off at MAC in April 2025. Clinical leads in the OPD attended the MAC to represent their relevant specialties. They told us collaborative and clinically insightful discussions were held.

Leads proactively reviewed governance arrangements which reflected best practice. OPD related governance structures included monthly quality and safety meetings. Here relevant leads reviewed performance data and compliance. They organised evidence under six categories: people’s experience, staff feedback, partner feedback, observation of care, processes, and outcomes. This ensured a comprehensive and transparent approach to quality and compliance.

We reviewed minutes from the department’s last three staff meetings in April, June and August 2025. There was an action log updated at every meeting where responsible leads reminded staff of clinical best practice. We also saw examples of OPD specific actions from the hospital’s bi-monthly health and safety meetings.

Leads and managers were aware of key areas of risk which affected their services. The hospital had some legacy risks relating to estates and facilities maintenance issues from our last inspection. These were being addressed and completed. For example, the roof was being repaired at the main hospital site during our onsite assessment.

Service-specific risks were frequently reviewed and escalated appropriately. The OPD’s top risk on the hospital’s risk register was uneven car park surfaces and manual entrance doors in front of the department (RSK-113). Actions were in place to mitigate this risk and keep patients and staff safe from trips, slips or falls. For example, floodlights were installed near reception, and leaves were blown or swept away from the entrance.

However, key clinical governance documentation had expired and was overdue for review. This was due to events beyond the department manager’s control, such as long-term senior staff sickness. For example, clear eligibility criteria had not been reviewed since June 2025. The manager had taken actions to resolve this. They explained the criteria would not need to change much. After planned review dates were postponed, they were pushing forward to work with another anaesthetist.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

The hospital actively fostered cross-site team development through engaging and inclusive activities. Examples included the York dragon boat race and guided paddle,boarding sessions. These helped strengthened collaboration, well being, and shared culture across departments.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

The department had a clinical fellow assisting the consultants. We heard this was the first such role of the provider hospital group. The fellow saw mostly follow up patient appointments. This allowed consultants to see more newly referred patients. Consultants told us the fellow was a practical extra resource reflective of their NHS joint venture and positive relations.

The department had examples of staff-led quality improvement projects. One example was devising bespoke care information after receiving patient feedback. This reflected many patients were unsure how to care for their leg and wound after a supportive boot was applied. In response the OPD team collaborated with orthopaedic consultants and patient representatives to co-design a bespoke supportive boot information leaflet. Patients reported feeling more confident in managing their recovery, and staff noted less unnecessary follow-up calls.

OPD introduced a series of 30-minute focused workshops. These were aimed at enhancing staff knowledge and confidence in key service areas. The workshops provided a safe space for learning, discussion, and reflection. They were well-received by staff, who reported increased clarity and practical insight. This initiative supported a culture of shared learning, a commitment to team development and continuous improvement.