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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has remained good.

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

We checked that 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 that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 79 (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, well being and communication needs with them.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment were effective by assessing and reviewing their health, care, well being, and communication needs with them.

Staff had completed comprehensive health and risk assessments for patients in a timely manner. Initial assessments took place in the pre-admission clinic and included previous medical and surgical histories, any history of sepsis, current medicines, allergy status, communication and capacity needs, weight, and health questionnaires. Complex cases were discussed to determine whether patients could be safely treated at the hospital. Patients outside ASA 1 and 2 criteria were referred to their GP or NHS Trust consultants for treatment.

A review of 10 patient records confirmed that information was personalised, risks were documented, and risk assessments were updated in line with policy. Nine of 10 records showed patients were involved in planning their care. Clear explanations of procedures were given, and consent was obtained for blood samples and MRSA screening. Patients requiring additional support were allocated extra time for appointments and offered hospital tours prior to admission. A dedicated side room was available for patients with dementia-type conditions.

Staff assessed and met patients’ nutrition and hydration needs. Seasonal menus were available for both private and NHS patients, and chefs could be contacted for additional dietary support. Allergens were clearly displayed in kitchen areas. Protected mealtimes were observed, and additional food options were provided when required. Family and visitors could access drinks on request. Staff handling food had completed food hygiene training and certification.

Nutritional risks were identified during pre-assessment, and weights were recorded at initial outpatient appointments. Malnutrition risk assessments were completed when needed. Patient charts confirmed food and fluid balance monitoring for those requiring intervention.

Pain management was addressed proactively. At initial assessment, pain levels were explored using a numerical scale, and pain charts were incorporated into NEWS2 documentation. Nine of 10 patient records contained pain charts, and pain levels were monitored and escalated when necessary. Pain management services were supported by consultants from the local NHS Trust, with inpatient care led by a designated consultant anaesthetist and 24-hour on-call anaesthetic cover. Governance updates were communicated to anaesthetists regularly. Staff identified trends in opioid-related nausea, and practice was adjusted to reduce doses accordingly. Patients received pain relief tailored to their needs.

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

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff had actively participated in clinical audits, bench marking, and quality improvement initiatives. The service completed tendable audits for the hospital environment, and evidence from the corporate team confirmed that Clifton Park Hospital had consistently bench marked as either first or second against other Ramsay Group hospitals in the UK.

Professional guidance was followed in the recording and management of medical device implants through national and local systems, policies, and compliance measures. All implants were recorded on either the National Joint Registry (NJR) or the Ramsay local implant register, ensuring traceability and data integrity. The organisation achieved NJR Gold status, reflecting excellence in data submission and adherence to national standards. The medical device management policy included processes for new devices.

The service participated in national bench marking audits, including NJR, Patient Reported Outcome Measures (PROMs), and Surgical Site Infection (SSI) surveillance. Policies and standard operating procedures were evidence-based; a review of five policies confirmed they were current and in date. Observations in theatres demonstrated adherence to evidence-based practice, including:

The maintenance of patients’ temperature within normal range to reduce infection risk, operative blood loss, and length of stay.

Risk assessment for venous thromboembolism (VTE), completed electronically during pre-assessment and reviewed by consultants. All surgical patients had a VTE assessment, and those at high risk were escalated for consultant review and prescribed prophylaxis, encouraged early ambulation, and hydration.

Warming cabinets were used to prevent perioperative hypothermia and improve outcomes.

National Safety Standards for Invasive Procedures (NatSSIPs) were used with high compliance in surgical safety checklist audits.

In line with National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommendations, Ramsay implemented a single electronic patient record system across all 34 sites, standardising risk assessments and patient pathways. This system enabled auditing and oversight of compliance with risk assessment completion and time-stamped documentation. The new incident reporting system supported the Patient Safety Incident Review Framework (PSIRF).

Decisions to operate on high-risk patients were made by consultants with multidisciplinary input. Patients requiring level 2 care were transferred to NHS pathways. The provider confirmed compliance with Core Standards for Pain Management Services in the UK, with a consultant-led outpatient pathway aligned to these standards. Although formal auditing had not occurred due to low private patient volumes, monitoring mechanisms, standardised documentation, and validated pain assessment tools were in place. NHS pathways included procedure delivery at Clifton Park Hospital, with pre-operative consultations and follow-up care provided at the local NHS Trust specialist pain service.

Sepsis screening and management were in line with national guidance. The team included or had access to the full range of specialists required to meet patient needs.

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

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had shared information about patients effectively during handover meetings, ensuring continuity of care between shifts. Teams maintained strong working relationships with other relevant departments, including discharge teams, consultant staff, and specialist services. Regular multidisciplinary meetings were held, including the daily 9:30 safety huddle, where discussions covered theatre lists, cancellations, patient numbers, outpatient activity, staffing, resuscitation bleep holder allocation, audit progress, and maintenance updates.

Consultant staff attended at weekends or out-of-hours when clinically required, and senior anaesthetist support was available 24/7. Patients were seen by their consultant within 14 hours of admission, ensuring timely review. Imaging and pharmacy services operated seven days a week, with a reduced service at weekends. Physiotherapy services were available on-site, and patients could access a small gym under physiotherapist supervision.

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

We scored the service as 4. The evidence showed an exceptional standard. The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff reported the service had committed to supporting patients to be as fit as possible for surgery, improving outcomes, and contributing to broader public health goals by addressing modifiable risk factors in a timely and coordinated manner. During pre-operative assessments (POA), patients received tailored advice and resources to encourage lifestyle changes, and collaboration with primary care providers ensured continuity of care and effective optimisation. Multidisciplinary teams (MDTs) reviewed complex cases to ensure appropriate pathways were followed.

At POA, patients were evaluated for key health factors, including obesity, smoking status, and diabetes management. These assessments were aligned with national health improvement strategies and discussed in MDT meetings to ensure a holistic, patient-centred approach. Patients who fell outside clinical criteria for safe surgical intervention due to unmanaged obesity, smoking, or poorly controlled diabetes were referred to their GP for optimisation, reducing perioperative risk and promoting better outcomes.

The hospital supported national priorities for improving population health by engaging with the local community and promoting health education. Recently, the hospital hosted an interactive educational event in collaboration with ‘Power Up to Play’, a charity initiative founded by medical professionals. The session featured one of the hospital’s expert hip and knee surgeons and was attended by over 50 local coaches and physiotherapists. Staff stated that learning from this event would be cascaded to football teams across the region, raising awareness of injury prevention and musculoskeletal health.

The physiotherapy team contributed to national health priorities by delivering structured non-weight-bearing (NWB) classes to prepare patients for surgery both physically and practically. Weekly sessions included discussions on home environment, transfers, self-care, and meal preparation, alongside practical training with mobility aids such as crutches and Zimmer frames. Equipment was arranged in advance to ensure patients were well-supported post-operatively.

Patients were referred to these classes by consultants, though attendance was optional at the time of inspection. Plans were in place to make attendance mandatory for patients over 40, with clinical triage available for younger individuals based on health status, comorbidities, and home support. This approach ensured patients were informed, confident, and equipped for recovery.

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

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff had access to clear policies, guidelines, and escalation pathways for managing deteriorating and septic patients. Recognised tools were used to detect and respond to clinical deterioration, including the National Early Warning Score (NEWS2). Training compliance for NEWS2 was 101.5%, and escalation processes were followed for scores above 4. A review of eight patient records confirmed NEWS2 scores were completed and monitored in recovery, with immediate escalation when deterioration occurred.

Learning from mortality and morbidity reviews was embedded in practice. Reviews of investigations were led by the corporate mortality and morbidity committee, and findings were discussed at the patient safety incident response group (PSIRG), clinical governance, and medical advisory committees. Learning was shared with the Integrated Care Board and regulator.

The hospital employed the Tendable audit programme, with the 2025–26 audit schedule displayed on-site. Audits were undertaken by deputy managers, and feedback was shared at ward meetings, handovers, and multidisciplinary huddles. The service-maintained compliance with HTM01-01 for decontamination processes, confirmed at 100% during the January 2025 audit, with additional weekly, monthly, and quarterly testing.

Accreditation's included NJR Gold Award for data quality, ANTT Silver Accreditation, and participation in the Getting It Right First Time (GIRFT) scheme. While the hospital was not part of the voluntary Anaesthesia Clinical Services Accreditation Scheme (ACSA), most anaesthetists worked within an NHS Trust accredited under ACSA. Ramsay appointed two specialist anaesthetic advisors in August 2025 to review external accreditation requirements.

Patient outcomes were monitored through Patient Reported Outcome Measures (PROMs), which improved responsiveness to post-procedure issues. Quarterly dashboards tracked outcomes for hip, knee, and shoulder surgeries, bench marked against Ramsay Health UK data, with no outliers identified. PROMs enabled proactive interventions, such as scheduling additional physiotherapy for patients reporting low scores, resulting in improved recovery. PROMs also informed prioritisation for patients awaiting procedures, including hip, knee, carpal tunnel, and cataract surgeries.

The physiotherapy team played a key role in managing the PROMs action register for orthopaedic procedures. They reviewed post-op survey responses against pre-op scores to identify issues and adjust treatment plans, ensuring optimal outcomes.

Weekly PSIRG meetings reviewed incidents, emerging themes, audit findings, infection control issues, and other governance matters. Data was submitted to the Private Healthcare Information Network (PHIN), and the hospital met milestone 7 for the April 2024–March 2025 publication period. Staff used technology to provide prompt access to blood test results and imaging scans, supporting timely clinical decision-making.

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

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Consent guidance and procedures had supported staff in following best practice. Informed consent training compliance was high at 97% (64 staff). For patients who might have impaired mental capacity, staff assessed and recorded capacity appropriately on a decision-specific basis for significant decisions. When patients lacked capacity, decisions were made in their best interests, considering their wishes, feelings, culture, and history. Staff took all practical steps to enable patients to make their own decisions.

Patients reported they were involved in decision-making and consent processes. A review of seven patient records confirmed consent had been obtained prior to procedures requiring consent. Staff confirmed initial consent was obtained during the consultant consultation, and if the procedure was delayed, consent was re-confirmed at 6–8 weeks. For plastic surgery, patients were given a two-week cooling-off period after initial consent, allowing time to reconsider or withdraw.

Audit data demonstrated improvement in compliance. The April 2024 consent audit identified compliance at 87% and highlighted areas for improvement. By October 2025, compliance had reached 100%. Plastic surgery cooling-off audits also improved from 83.7% in March 2025 to 90% in September 2025, following feedback and consultant engagement.