Clifton Park Hospital Limited

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• 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

This means we looked for evidence that the service met people’s needs. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

Good: This means we looked for evidence that the service met people’s needs.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff used person-centred approaches, incorporating input from patients and their carers to ensure care delivery was respectful, inclusive, and adapted to individual needs. Reasonable adjustments had been made in line with the Equality Act 2010, and all clinical staff had completed the Oliver McGowan mandatory online training. Heads of department and senior leadership had attended the in-person full-day course.

Staff had completed training in dementia awareness and safeguarding adults, which provided them with the knowledge required when caring for patients with complex needs. The learning disability lead supported staff and patients as needed.

Dementia, mental health needs, and falls risks were identified and assessed during the patient’s pre-assessment. Staff falls champions supported colleagues in implementing the new falls framework. A designated side room on the ward had been identified for patients with dementia-type conditions, allowing them and their carers privacy.

Patients with a confirmed mental health diagnosis who were receiving medication were reviewed by the anaesthetist and the multidisciplinary team (MDT) to ensure their needs could be met and reasonable adjustments identified and implemented during their stay. Mental Health First Aiders were based at the hospital for staff and patient support, and additional support could be requested via the psychiatry service at the local NHS trust.

Patients with autism spectrum disorders (ASD) were identified at the point of referral, which ensured staff could tailor care to individual communication needs, sensory preferences, and personal routines. Additional appointment time was allocated to allow a more flexible and supportive interaction, reducing stress and encouraging better engagement. Following the initial assessment, the responsible consultant was notified to ensure clinical oversight and continuity of care.

Where appropriate, patients were offered a pre-procedure hospital tour to familiarise them with the environment, reduce anxiety, and build trust with the care team. Tours included introductions to key staff, viewing clinical areas, and discussions about what to expect during their visit.

Patients who required high dependency unit care (level 2 post-operative care) were identified and escalated to the resident medical officer. These patients received one-to-one care and observations until they were transferred to the local NHS trust. Transfer paperwork was completed to ensure all relevant documentation accompanied the patient, supporting a smooth handover to the receiving ward. The following day, contact was made with the receiving hospital for an update on the patient’s condition.

Patients confirmed their involvement in care and decision-making processes. Records showed evidence of individual risk identification, supported by relevant risk assessments such as falls, moving and handling, pressure damage, and malnutrition assessments. Nine patient care plans reviewed confirmed they had been involved in planning their care.

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.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The hospital delivered and coordinated services considering the needs and preferences of different people, including those with protected characteristics under the Equality Act and those at risk of a poorer experience of care. (Please also refer to the person-centred care section of this report for further detail.)

The service worked closely with the local NHS Trust and another independent hospital within York, so potential patients were offered joined-up, flexible care and a choice of hospital for their treatment. Patient choice was sometimes limited by associated risks; however, a thorough pre-assessment process, alongside information from the patient’s GP and consultant, informed decisions so that patients were admitted to the hospital best suited to meet their needs.

When the service undertook NHS work, a structured triage and assessment process was followed to ensure patients met the appropriate clinical criteria. This process included:

Initial Screening: Patients were triaged through analysis of the health questionnaire and GP referral information. Those meeting initial clinical thresholds were listed for pre-assessment.

Inclusion/Exclusion Criteria: A RAG (Red-Amber-Green) rating system was applied to assess each patient against defined inclusion and exclusion criteria, determining if an anaesthetic review was required prior to treatment.

Multidisciplinary Team (MDT) Reviews: These were completed for patients presenting with social complexities or frailty concerns.

Emergency surgery was provided at night, weekends, and bank holidays. The theatre department’s on-call service ensured the following staffing was available: one scrub practitioner, one operating department practitioner, and one registered nurse circulator. On-call anaesthetic cover was provided through the local anaesthetic group, who shared their rota with the theatre manager a week in advance. The Clifton Park on-call rota was stored on the shared drive for staff access. If the on-call team was needed, the ward nurse contacted the team, surgeon, and anaesthetist to notify them to attend the hospital.

A car park was located at the front of the hospital for patient and visitor use only, ensuring easy access to the hospital site.

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

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Ramsay Health Care UK Limited, of which Clifton Park Hospital was part, had achieved Data Security and Protection Toolkit accreditation. This accreditation demonstrated that the service practised good data security and handled personal information correctly. The current certificate was valid until 30 June 2026.

The hospital adhered to the corporate data protection policy, and staff undertook annual data awareness training as part of mandatory e-learning. Compliance as of 30 September was 98.6%. Information governance systems ensured confidentiality of patient records.

The service complied with the Accessible Information Standard. Information was provided in formats accessible to the patient group. Interpreter services, hearing loops, large print, Braille materials, and dementia-friendly environments supported patients’ needs. Information leaflets were available in different languages. Staff ensured carers and families were regularly updated about the patient’s progress. The service used alerts and electronic patient records to flag special requirements.

Staff made notifications to external bodies as required. Safety, quality, and private healthcare cost information was submitted digitally to the Private Healthcare Information Network. Information boards kept staff, patients, and families updated about governance, surgical safety, and audit outcomes.

At scheduling meetings, electronic alerts such as fall risks were checked and discussed. Safety flash alerts were displayed in theatres for staff information.

Following five never events, staff reported they were involved in reviewing processes and implementing changes. We observed the new process for implant management and saw checks were carried out to ensure the correct implant was used. Staff confirmed that implant information was entered into the National Joint Registry and then added to the data set component label sheet.

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

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They involved people in decisions about their care and told them what had changed as a result.

Staff knew how to handle complaints appropriately and protected patients who raised concerns or complaints from discrimination and harassment. Patient feedback was shared with the hospital board to support learning and reinforce good practice, and themes were shared with staff as part of lessons learned so that proactive actions were implemented to embed improvements. Staff reported that both positive and negative feedback was shared at the hospital performance meeting. The hospital received 35 patient compliments between October 2024 and September 2025.

Complaints leaflets were available for patients to take and read at leisure, providing guidance on how to complain. Patients knew how to raise concerns, and when they did, they received feedback.

The hospital had adopted the corporate complaints policy. The Clifton Park complaints register (October 2024 to September 2025) confirmed the hospital received six formal complaints, three of which related to communication breakdowns or cancellation of surgery. Actions identified included monitoring of a specific service.

To proactively manage patient dissatisfaction, the hospital captured all informal complaints onto the incident reporting system. There were 13 informal complaints recorded between 15 October 2024 and 5 June 2025, all of which were closed. Different themes emerged, with eight relating to care or discharge concerns.

Patient complaints, both formal and informal, were escalated as part of the customer focus group, with actions identified to mitigate future concerns.

We make sure that everyone can access the care, support and treatment they need when they need it.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The hospital access policy was governed by the principles outlined in the Ramsay waiting list policy and access policy (v11.2). This policy ensured transparent and equitable access to NHS treatment, compliance with NHS referral-to-treatment (RTT) standards, prioritisation based on clinical need, and patient rights under the NHS Constitution. It also integrated national guidance and evidence-based interventions. The hospital oversaw the elective waiting list and applied established protocols for did-not-attend (DNA) management, active monitoring, and inter-provider transfers in accordance with organisational policy.

Between October 2024 and September 2025, the hospital recorded 5,205 admissions, of which 2,236 were inpatient admissions and 2,969 were day-case admissions (57% day-case). Staff confirmed that the hospital and Ramsay Health Care UK operated in line with government targets for waiting times. The referral-to-treatment target was 65% of all patients treated within 18 weeks. In the last year, the percentage of patients treated within 18 weeks increased from 48% to 70%.

Less than 1% of the total waiting list had waited more than 52 weeks. As of 6 October 2025, three patients had waited over 52 weeks, representing 0.4% of the total waiting list.

The surgical day unit operated from 7am, and patients requiring additional support were transferred to the inpatient ward prior to the closure of the surgical unit. Admission lists were staggered at 7.30am and 11.30am respectively. Patients listed for surgery were assessed based on clinical urgency and the duration since referral, so individuals with the greatest clinical need were prioritised. The inpatient bookings team managed patient scheduling in accordance with clinical priority and chronological order. At each point of contact, patients were validated to confirm the continued appropriateness of the procedure, both in terms of clinical need and suitability for treatment. Waiting lists were reviewed weekly, and a fortnightly report was presented to the senior leadership team.

On the day of admission for surgery, the order of the surgical list was determined primarily by clinical factors. Priority was based on patient-specific considerations such as co-morbidities and age. For example, patients with diabetes were scheduled earlier in the day to support optimal clinical outcomes.

Staff made reasonable adjustments for patients, such as providing walking aids and shower chairs for those with mobility issues. Staff confirmed they had adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. Staff planned for patients’ discharge, which included liaison with care managers, families, and carers. Discharge was never delayed for reasons other than clinical need.

The service confirmed that no patients returned to theatre within the past six months. However, two patients who initially had surgery at the hospital were readmitted to the local NHS trust within six months of their procedures. Investigations were instigated for both cases to identify learning and ensure actions were implemented. There were no patient readmission's to Clifton Park Hospital within two days of discharge.

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

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Please refer to the person-centred care section of this report, which describes how the hospital identified and listened to information about people who were likely to experience inequality in experience or outcomes, including those with protected characteristics under the Equality Act or people with multiple needs or health conditions, and how care was tailored to support these patients.

Staff ensured that all potential patients’ risks and care needs were identified at the pre-assessment clinic so that adjustments could be put in place to facilitate their care pathway. Discharge planning with members of the multidisciplinary team commenced prior to admission to ensure the right support was in place for the patient on discharge.

Staff had completed Level 1 equality, diversity, and human rights training, and one senior manager had completed equality, diversity, and human rights training for senior managers. All staff had completed modern slavery, anti-bribery, fraud, and corruption training, which helped staff identify patients at risk, understand their needs, and ensure that current and discharge care arrangements were suitable.

Staff within the service and the wider organisation promoted a culture in which people using the service felt empowered to give their views. Patients we spoke with said they felt able to speak with staff about any concerns they had.

Patients’ views were captured through the annual Friends and Family Test survey. Patients participated by completing a physical feedback card or by scanning a QR code displayed on posters and flyers throughout the hospital. Monthly feedback included satisfaction scores and written comments. Additional feedback was captured from inpatients through the patient feedback survey post-discharge. The digital survey captured patients’ perspectives on various aspects of their care throughout their healthcare journey.

The patient participation group was relaunched in 2024. Patients and/or the public were part of the team in the hospital’s November 2024 Patient-Led Assessment of the Care Environment (PLACE) audit. The PLACE assessment evaluated non-clinical aspects of the environment such as cleanliness, food, hydration, and how the premises supported privacy, dignity, and the needs of patients with disabilities and dementia. The assessment site scores ranged from 84.78% (privacy, dignity, and well being) to 99.33% (cleanliness). The six remaining areas of compliance were rated between 88.57% and 98.10%.

The hospital implemented systems to manage patients who did not attend (DNA) for surgery on their scheduled admission day. The 48-hour pre-admission telephone check identified patients who no longer wished to proceed. Reception staff monitored arrivals on the day of admission, initiating contact within 30–60 minutes of a missed check-in. Where consent was provided, voicemail messages were left to encourage patient response. These processes ensured that patients were either re-engaged or appropriately removed from the surgical pathway. Hospital data confirmed that DNA rates and cancellations made within 48 hours of admission were generally low and that 48-hour calls were consistently higher than DNA counts.

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.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients in making decisions about their care, treatment, and future. Patients were involved in planning their care, and staff created personalised care plans that reflected the patient’s needs, wishes, and feelings. Staff reported that they had not cared for people nearing the end of life, as no patients had been admitted who required this support. Staff said that if they had concerns about a patient, they would approach the head of clinical services for advice.

Staff ensured that all relevant healthcare professionals and other appropriate bodies were involved in planning the care and treatment of people with complex needs. Guidance on the Do Not Resuscitate (DNR) policy was available for staff to access when required.