Clifton Park Hospital Limited

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• 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 we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.

Good: This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Clifton Park Hospital demonstrated a strong culture of safety and transparency within its surgical services. Staff were clear on what incidents to report and how to report them and described a positive reporting culture where they felt safe and encouraged to raise concerns, near misses, and feedback. Between October 2024 and September 2025, 281 incidents were recorded on the hospital’s risk reporting system (RADAR), with main themes relating to theatres (110), wards (96), and consultant cancellations (59).

Staff understood the duty of candour requirements and had access to policy guidance. The hospital confirmed 100% compliance with mandatory e-learning on ‘Essentials of Patient Safety,’ which included duty of candour training. Staff demonstrated openness and transparency when things went wrong, providing patients and families with full explanations, as documented in the never events report.

In 2024, the service identified five never events, which are serious, wholly preventable patient safety incidents. Investigations resulted in 26 recommendations, of which 24 had been implemented. Evidence of completion and compliance was stored within the hospital’s electronic incident system. The remaining two actions—civility saves lives training (scheduled for 11 November 2025) and streamlining prosthesis stock consignment—were in progress. Monitoring of practices was ongoing through audits, and learning was displayed on staff boards. A new list safety officer role had been introduced in theatre areas following these events.

Staff confirmed they received debriefs and support after never events. Oversight was maintained through committees such as the Patient Safety Incident Response Group (PSIRG), Clinical Governance, and Medical Advisory Committees. Meeting minutes confirmed active discussion of incidents and feedback dissemination. Audits in July 2025 showed full compliance in prosthesis safety checks and theatre debrief processes.

Patient deaths were managed under the Patient Safety Incident Response Framework (PSIRF), with investigations conducted using the PSII format. Findings were presented to the Mortality and Morbidity (M&M) group and shared across Ramsay Health Care UK. Outcomes and key learnings were cascaded to clinical leads and shared with local NHS Trusts, Integrated Care Boards, and regional forums, ensuring system-wide learning and improvement.

We work with people and our 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.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Clifton Park Hospital demonstrated robust systems for patient referral, admission, and continuity of care. Referral and admission processes ensured all essential patient information was received to confirm that needs could be safely met. A review of 10 electronic patient records confirmed completion of risk assessments and preoperative processes prior to surgery. Observations of pre-assessment clinics showed thorough consent procedures, review of medical and medication histories, risk assessments, and pre-admission checks, including vital signs, ECG, blood tests, and weight recording.

Staff worked collaboratively with healthcare and social care services to maintain safe care continuity post-discharge. Meetings with the local NHS Trust (29 July 2025) confirmed strong partnership working to improve patient experience. Records audits for August and September 2025 demonstrated 100% compliance with discharge processes. A critical care agreement and standard operating procedure was in place with the local NHS Trust for urgent transfers requiring level 1–3 care.

System partner meetings (25 July 2025) evidenced shared learning and safety improvements, including a reduction in serious incidents. Weekly scheduling meetings ensured effective planning of theatre and ward activity, with representation from key departments and actions documented and shared.

Compliance with Royal College of Anaesthetists (RCoA) guidelines for postoperative care was confirmed. All PACU staff completed competency packs and were trained in immediate life support, with advanced life support (ALS) coverage provided by permanent and bank staff, supported by the resident doctor when required.

The service adopted Ramsay Health Care UK’s corporate Safer Surgery and Invasive Procedures policy (C N-006), aligned with National Safety Standards for Invasive Procedures (NatSSIPs). Observations confirmed consistent use of the NHS surgical safety checklist in theatres, and audits demonstrated high compliance: annual list safety officer and safer surgery reports showed compliance between 95.8% and 96.6%, while prosthesis audits ranged from 90.5% to 95%. September and October 2025 audits confirmed continued strong compliance.

Discharge audits for August and September 2025 confirmed 100% compliance, ranking Clifton Park Hospital first and second within its group. Out-of-hours escalation was supported by a resident medical officer and an on-call senior leadership team member. Patient safety alerts issued via the Central Alerting System (CAS) were tracked by the corporate team to ensure timely action.

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, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Clifton Park Hospital had robust safeguarding governance processes and leadership in place. A nominated Safeguarding Lead (SGL) oversaw safeguarding activity locally, supported by national safeguarding leads (NSGLs) for adults and children. The SGL networks worked effectively with the local authority, NHS Trust, and the wider Ramsay Health Care UK group to ensure best practice and compliance.

Although the hospital reported few safeguarding referrals, referrals were logged on the risk management system, which automatically alerted NSGLs, the Chief Clinical and Quality Officer / Clinical Director, who was the PREVENT Lead and Executive Board member responsible for safeguarding. Safeguarding priorities were outlined in the Ramsay Health Care UK Safeguarding Adults and Children’s Report 2024 and the Annual Plan 2025, which detailed objectives for January–December 2025 and reviewed activity for 2024.

Comprehensive adult safeguarding guidance included protocols for child exploitation, PREVENT, restraint, and female genital mutilation (FGM). Chaperone policies were in place, and FGM guidance incorporated into induction safeguarding training. All new staff had Disclosure and Barring Service (DBS) checks prior to employment.

Training compliance was strong and ranged from 99.3% to 100%. The hospital safeguarding lead was trained to level 3, and the Head of Clinical Services held level 4 training. All surgical ward and theatre staff had completed Level 2 safeguarding training. Additional mandatory training included dementia awareness, Mental Capacity Act, and Deprivation of Liberty Safeguards.

Safeguarding supervision was available to the SGL, although a summary of staff safeguarding supervision for 2024/25 was not provided at the time of review. Staff demonstrated clear understanding of safeguarding responsibilities, including how to raise alerts and identify adults at risk of harm. They described working collaboratively with external agencies and gave examples of protecting patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

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.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff ensured that patients could access advocacy and enabled patients to give feedback on the service they received, for example, via surveys.

Staff followed patient pathway standard operating procedures to ensure patients’ needs, care and risks were identified.

All patients were risk assessed preoperatively using the American Society of Anaethesiologists (ASA) physical status classification. ASA is a system from 1 to 6 which identified the patient’s pre-operative health status, including operative risk. Staff confirmed the hospital admitted patients rated 1 (normal, healthy patient) or 2 (patient with mild systemic disease) only. If the patient had surgery previously previous issues with anaesthesia checks were made to inform the team of potential risks.

In addition, guidance produced in association with the anaesthetics group informed decision making as to the patients’ suitability for treatment at the hospital. Clear criteria identified patient risk levels which could indicate an anaesthetic review was required or the procedure cancelled.

Escalation pathways advised on the deteriorating patient and septic patient. Clinical staff had pocket cards to understand the impact of the deterioration. All clinical staff completed NEWS2 mandatory e-learning 2-yearly; current compliance was 97.9%. Patient deterioration was monitored through recognised tools such as the national early warning score (NEWS2) and sepsis screening tool. We reviewed 8 patients completed NEWS charts. NEWS2 audits were completed twice yearly; the September 2025 audit (99.3%) showed a significant improvement from March 2025 (87.5%). Following the audit feedback was given to the recovery and ward staff, to improve documentation.

Additional risk assessments were completed at pre-admission stage, for example, venous thromboembolism (VTE) and falls risk assessment. A bed risk assessment would be completed on the ward should the patient be at risk of falls.

Monitoring of risk assessments took place, for example 2 pre-operative risk assessment audits in September 2024 (93.9%) and March 2025 (98.8%) confirmed good compliance to standards. These audits included a review of 10 patients records.

The hospital followed the venous - thromboembolism (VTE) prophylaxis policy (CM-001). VTE risk assessments were completed for all patients admitted and recorded on the patient electronic patient record. Compliance against monthly VTE audits was high; 98.3% for audits carried out in August and September 2025.

A corporate falls framework and falls monitoring were in place. The May 2025 essential care falls prevention inspection report for the whole hospital, and the monthly tendable September 2025 falls prevention summary confirmed an improvement in compliance to 100% from 78.3% noted for the May 2025 audit. The September 2025 summary showed an improvement in the hospitals ranking in this area from 3 to 1 when bench-marked against other hospitals within the Ramsey hospital group.

Patients’ frailty status was also assessed against the clinical frailty scale whose range was from 1-9 (very fit to terminally ill).

Patients who required physiotherapist input were seen by the physiotherapist prior to discharge home.

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

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Clifton Park Hospital’s surgical service environment was found to be well maintained and fit for purpose. The service comprised a 24-bed inpatient ward, a day care unit, a physiotherapy department with a small gym, and three theatres. Access to surgical units and theatres was secure via swipe card, and visitor entry was monitored through a camera and bell-controlled access panel.

Security governance followed the Ramsay Central Alerting System (CAS) policy, with alerts disseminated through the corporate CAS and tracked via the incident system. The hospital confirmed there were no outstanding alerts. The quality improvement manager ensured alerts were distributed to relevant departments and responses coordinated.

Infection prevention and control (IPC) measures were robust. Legionella testing in February 2024 identified actions, which were tracked through an action plan. IPC committee minutes (26 September 2025) confirmed water safety testing for legionella and pseudomonas was completed in May 2025 at the main site and March 2025 in the modular theatre, with no issues identified. Legionella risk assessments remained under constant review. Annual air handling validations for theatres and treatment rooms in July 2025 identified no concerns.

Equipment safety checks were generally compliant. Random checks confirmed most equipment had service stickers or safety testing completed. Two thermometers on the ward were overdue servicing. Maintenance records showed ongoing servicing, though 24 pieces of theatre equipment (18.9%) and 5 ward items (4.1%) were overdue maintenance. Portable appliance testing was confirmed as completed. Anaesthetic machine daily checks achieved 100% compliance from October 2024 to October 2025, with logbooks maintained for all theatres. Faults resulted in postponement of operating lists until resolved.

Fridge temperature monitoring for food and medicines was compliant, with no concerns raised. Implant traceability was robust, with all prostheses recorded in patient electronic records and on the National Joint Registry (NJR) system. The hospital’s systems enabled rapid reporting of implants and equipment to the healthcare products regulator.

Fire safety training was delivered at induction and refreshed annually. The last fire drill took place on 26 June 2025, and the fire risk assessment in August 2025 identified four actions, two of which remained due for completion by December 2025. Resuscitation trolleys were checked daily and weekly, with no gaps observed. However, the diabetic box for the day unit trolley was initially stored outside the trolley due to space constraints; this was escalated and corrected promptly. Quarterly resuscitation audits showed compliance between 87.5% and 100%, with the lower score due to a missing MRI-safe sticker, which was rectified.

Additional checks were completed on invasive procedure trolleys, anaesthetic equipment, transfer bags, warming cabinets, blood fridges, and monitoring machines. Medical gas cylinders were stored securely in locked cages, and COSHH products were locked away in compliance with regulations.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Clifton Park Hospital maintained structured workforce planning and staffing governance to ensure safe and effective care. Senior managers agreed staffing requirements during annual budget meetings, supported by annual departmental establishment reviews based on historical activity and projected demand. This process ensured appropriate staffing levels and skill mix across services.

The theatre department adhered to Association for Perioperative Practice (AFPP) standards for theatre staffing. The inpatient ward operated under a level 0 designation, meaning patients’ needs were met through normal ward care, with a staffing formula of one nurse and one healthcare assistant per eight patients. Off-duty rotas were produced six weeks in advance and aligned with theatre lists, which were reviewed weekly. Wednesday scheduling meetings ensured staffing adjustments for patients with additional needs, such as 1:1 care for individuals with dementia.

Out-of-hours support was provided by a clinical senior ward nurse and an on-call theatre team covering seven days a week, comprising an Operating Department Practitioner (ODP), scrub nurse, circulator, and anaesthetist. Agency and bank staff were deployed, when necessary, with induction provided to ensure familiarity with hospital processes. Managers addressed poor performance promptly and effectively.

Workforce metrics for surgery indicated a low turnover (1.28% in theatres from October 2024 to September 2025) but a higher sickness rate of 20.05% in theatres.

Medical staffing was managed through practicing privileges agreements for consultants, with compliance checks on registration, indemnity insurance, and annual appraisals. As of 13 October 2025, all consultants held valid indemnity insurance. Consultants provided evidence of mandatory and specialty-specific training. Adequate 24-hour medical cover was maintained through resident doctors (RDs) and consultants, with access to anaesthetic consultants and NHS Trust medical registrars for advice. Senior staff confirmed trainee doctors attended the hospital for learning opportunities.

Mandatory training compliance was high, with an overall e-learning completion rate of 99.6% and face-to-face module compliance at 95.1%, exceeding the hospital’s 95% target. Immediate Life Support (ILS) training compliance was 88.7% (71 of 80 staff), reflecting new starters awaiting training, while Basic Life Support (BLS) compliance was 98.2% (55 of 56 staff). RDs had completed Advanced Life Support (ALS) training.

Managers identified specialist training needs and provided opportunities for staff development. Induction processes included a one-day corporate induction followed by a three-month hospital induction covering mandatory training, policies, and equality, race, sexual harassment, and safeguarding awareness. Appraisal compliance for 2024/25 was high: 95.2% for nursing staff (20 of 21) and 100% for medical staff, allied health professionals, and other groups. Staff confirmed access to regular team meetings and clinical supervision.

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

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Healthcare-associated infection (HCAI) prevention and control had been well coordinated across the hospital. The Head of Clinical Services acted as the designated Director of Infection Prevention and Control (DIPC), ensuring robust surveillance systems were in place and all infection incidents were reported through the internal incident reporting system. Staff confirmed the use of the Patient Safety Incident Response Framework (PSIRF) to investigate and learn from incidents, with findings reviewed at the infection prevention and control committee, clinical governance committee, and medical advisory committee. The DIPC also oversaw submissions to the UKHSA Surgical Site Infection Surveillance Scheme (SSISS) and reported serious incidents, outbreaks, and clusters to the National Clinical Lead for IPC.

The hospital had presented its annual IPC report for 2024 and developed an IPC plan for 2025. The IPC team included a dedicated lead and link staff within departments, all of whom had received additional training through national training days or the Ramsay Health network. A service-level agreement with the local NHS Trust provided access to a named consultant microbiologist, including out-of-hours support.

Staff had access to comprehensive IPC guidance, including MRSA screening and management protocols. Surgical site infection audits confirmed that from October 2024 to September 2025, no MRSA or Clostridium difficile infections were identified. Patients were risk assessed and screened for MRSA prior to admission, and those undergoing joint replacement or metalwork procedures received MSSA decolonisation treatment five days before admission.

Audits demonstrated strong compliance with infection control practices. Peripheral vascular access device audits improved from 89.3% in July 2024 to 91.5% in August 2025, with ongoing staff education. Urinary catheterisation bundle audits showed high compliance at 96.3% (November 2024) and 98.7% (October 2025). Hand hygiene audits averaged 92.14% over six months, with immediate feedback and education provided where standards were not met. HTM01-01 compliance for decontamination of reusable medical devices was confirmed at 100% during the January 2025 audit.

Ward and theatre areas were visibly clean, well-maintained, and appropriately furnished. Cleaning records were up to date, and audits confirmed high standards of cleanliness: 92.81% for wards and 95.76% for theatres between April and September 2025. Disposable curtains were in use, and shower curtain changes were documented every three months. Domestic staff were appropriately trained and supported, and cleaning audits such as the ‘50 Steps Cleaning’ audit were completed regularly.

Hand hygiene training was part of mandatory training, delivered through e-learning and annual face-to-face sessions led by IPC link nurses. Clinical staff completed aseptic non-touch technique (ANTT) competency assessments supervised by trained assessors.

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.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happen.

Staff had followed good practice in medicines management, including transport, storage, dispensing, administration, reconciliation, recording, disposal, and covert medication, in line with national guidance. Each department where medicines were used maintained a medicines management file, and staff had signed to confirm they understood the policy and relevant standard operating procedures.

Medicines, including controlled drugs (CDs), were stored securely, with daily stock checks completed by two staff members. CD key control logs were maintained in bound books, and destruction registers were in use. FP10 prescription forms were used appropriately when the pharmacist was not on site, and logs confirmed compliance. Biannual stock takes and quarterly reviews ensured expired drugs were removed, and findings were shared with all departments.

Medicines were prescribed using an electronic prescribing and medicines administration (ePMA) system. A review of 10 patient charts confirmed allergies, height, and weight were documented, and anticoagulants were prescribed correctly according to weight. Medicines reconciliation was completed within 24 hours of admission and again on day one post-surgery, with regular reviews during ward rounds.

Monitoring processes included medicines reconciliation audits and CD audits, which showed improvement: reconciliation compliance increased to 97.1% (January 2025) and CD audit compliance to 93.9% (March 2025). Actions from audits were implemented and shared with staff at governance meetings. Room, fridge, and freezer temperatures were monitored consistently.

The hospital had adopted local NHS Trust antimicrobial guidance, although the adult antimicrobial formulary had passed its review date of March 2024. Antimicrobial stewardship and prescribing audits demonstrated 100% compliance, and drug chart reviews confirmed good practice. Antibiotic use in orthopaedic surgery was monitored daily by the pharmacist, and antimicrobial stewardship data was reviewed quarterly by the IPC team, which included the local Trust’s lead microbiologist.

Staff had access to laminated antimicrobial guidance posters in anaesthetic rooms, wards, and outpatient areas. Intravenous fluids and medical gases were managed safely, with gases stored in locked cages. Training compliance was strong: 100% of staff completed drug calculation assessments, and intravenous drug competency was confirmed through face-to-face sessions. Antimicrobial stewardship e-learning was completed by clinical staff, and annual medical gas safety training was available, although completion data for 2024/25 was not provided.