Clifton Park Hospital Limited

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• 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 we 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.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Discussions with staff confirmed they were satisfied with the hospital’s culture, leadership, processes, and involvement. Staff knew and understood the provider’s vision and values and how these were applied in the work of their team.

The provider’s senior leadership team successfully communicated its vision and values to front line staff in this service. The ‘Ramsay Way’ identified the values which were shared with new staff as part of induction. The Ramsay Way outlined three main approaches to daily work: building strong relationships, constantly improving, and growing sustainably.

The hospital strategy was built on these values. Staff had the opportunity to contribute to discussions about the strategy for their service, particularly where changes were planned. Sessions were held with staff to capture feedback about the new strategy and develop action plans relevant to individual departments. Senior staff reported that the aim was to have the strategy agreed on and in place by October 2025. The strategy’s main headings included: people and culture, operational excellence, scale and growth, and clinical excellence. Staff said they aimed to incorporate the hospital strategy into the staff appraisal process.

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

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness, and honesty.

Leaders had the skills, knowledge, and experience required to perform their roles. They demonstrated a good understanding of the services they managed and were able to explain clearly how teams worked to provide high-quality care. Leaders were visible within the service and approachable for both patients and staff.

Leadership development opportunities were available, including opportunities for staff. Staff reported feeling supported by the senior leadership team and said they had been encouraged to develop within their roles. Staff confirmed they could access training through the Ramsay Academy, which they described as very good.

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

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in ways that reflected their individual needs. Patients, staff, and carers were involved in decision-making about changes to the service and could meet with members of the provider’s senior leadership team to share feedback.

Staff were encouraged to speak up through the ‘Stand Up for Safety’ initiative. Staff had attended face-to-face training for the programme, with compliance recorded at 96.5%. One staff member was accredited by an external institute to deliver the programme internally. New staff completed ‘Speak Up for Safety’ training during induction. Staff reported that although there was no Freedom to Speak Up guardians on site, the senior leadership team was very approachable, which meant they felt comfortable raising patient safety and care issues.

The programme used the Safety Check, Option, Demonstrate, and Escalate (C.O.D.E.) model developed by the institute to guide staff in raising concerns. There were no safety CODE escalations in the last 12 months.

Staff could also speak up through the national Speak Up email and whistle-blowing email systems, both of which allowed anonymity and assured confidentiality. Staff were informed they could contact the health regulator if needed. Posters were displayed throughout the hospital with telephone and email contact details for these processes.

Employee suggestion boxes were located throughout the hospital. Staff said concerns were often raised during staff meetings or submitted via the ideas box, after which they were discussed as part of the meeting. Staff described being proud of the hospital culture and confirmed that an open-door policy was in place should they need to raise any queries or concerns.

The annual report for Ramsay Health Care UK (1 July 2024 to 30 June 2025) identified that no concerns had been raised. It was recommended that the executive team and senior leaders maintain visible support for the Freedom to Speak Up programme, ensure policies remained accessible and clear, and provide regular opportunities for colleague engagement and feedback. The future focus was for the guardian to increase awareness, contribute to locally delivered training, and refine processes to make speaking up even more accessible and effective.

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.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had completed Level 1 equality, diversity, and human rights training, and one senior manager had been identified to complete equality, diversity, and human rights training for senior managers.

Managers put reasonable adjustments in place for staff members to help them carry out their roles. Staff were able to apply for flexible working arrangements to accommodate personal circumstances such as caring responsibilities and health issues.

Staff views were captured through staff meetings and surveys. When staff could not attend meetings, they accessed updates in the communications file located in the staff coffee room. Morning meetings were held daily where key messages were shared with staff.

The Workforce Race Equality Standard (WRES) was embedded at Ramsay Health Care UK, which Clifton Park Hospital followed. Senior staff confirmed WRES was monitored at a corporate level. The 2025 WRES corporate report (April 2024 – March 2025) described systems for monitoring and improving race equality across the workforce and confirmed the organisation’s commitment to equality, diversity, and inclusion. Monitoring of WRES was ongoing, and WRES indicators were reviewed yearly in conjunction with data from the human resources information system (HRIS), Workday, and staff engagement surveys. The annual report was approved by the executive board, shared with governance committees, and published on the company website.

Ramsay Health Care UK monitored key measures such as staff ethnicity, recruitment, disciplinary processes, access to training, and board representation. These were analysed and bench marked against sector standards. Action plans were created and tracked, which included annual campaigns to encourage self-reporting, regular analysis of trends, and targeted interventions to address any disparities. Progress was overseen by dedicated roles and governance forums, which ensured accountability and promoted a culture of continuous improvement.

We have clear responsibilities, roles, systems of accountability and good governance 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.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance information clearly identified respective roles, responsibilities, and accountabilities. Staff were aware of the governance framework, and oversight was maintained through committees and groups, including heads of department, clinical governance, and medical advisory committees (MAC).

Staff confirmed that ward-to-board, regional, and national communication pathways existed. Learning from incidents and complaints, new guidance, and feedback were discussed at committees, ward, and team meetings. Staff said recommendations from reviews of never events, incidents, and complaints had been implemented. We heard about the learning and observed changes resulting from the five never events.

Staff undertook or participated in local clinical audits, which were sufficient to provide assurance. Staff acted on audit results when needed. Audit data and reports were tracked in the business intelligence platform used by the hospital group. This data produced overviews and clinical quality information, informing compliance, identifying issues, and tracking progress. Hospitals within the Ramsay Hospital Group UK were bench marked against each other, which identified progress made in the areas assessed.

Staff understood arrangements for working with other teams, both within the hospital and externally, to meet patients’ needs. The national director of clinical services held the corporate role of Caldicott Guardian and was responsible for standards of medical records management within Ramsay Health Care UK. Staff completed e-learning on information security and sharing, with compliance recorded at 100%.

The Medical Advisory Committee (MAC) held a central role in clinical governance and consultant oversight. Facility rules defined MAC roles and responsibilities. Quarterly MAC meetings included a 30-minute credentialing session where applicant medical staff credentials were verified, and appraisal and medical indemnity status were confirmed. Business and hospital updates were also shared and discussed at these meetings.

Hospital systems ensured consultant staff complied with the Competition and Markets Authority (CMA) Order regarding the prohibition of inducing a referring clinician to refer private patients to or treat private patients at the facility.

Team managers could access information to support their management role, including service performance, staffing, and patient care. Information was timely, accurate, and identified areas for improvement. Cost improvements did not compromise patient care.

Hospital performance was measured monthly using Ramsay’s key performance indicator (KPI) scorecard, which provided metrics on new business, clinical activity, staffing and agency use, financial performance, and people. The clinical data quality pack monitored clinical procedures and risks, tracked feedback and operational concerns, and supported audit and compliance processes. This reporting tool was a live document that updated as the risk management system updated. The dashboard shared performance against other Ramsay hospitals for reporting clinical incidents compared to admissions. The number of incidents as a proportion of admissions for Clifton Park was 8.32% (Ramsay identified 5% and above as an outlier).

Sepsis management guidance was in place. When patients developed infections, including sepsis, incidents were reported and reviewed daily by the infection prevention and control (IPC) lead and another manager to identify early reviews and learning. Incidents were reviewed at weekly PSIRG meetings. Significant infections were discussed and escalated to national forums for awareness and learning. The IPC report was independently reviewed by a consultant microbiologist. Further discussions took place at the IPC committee and were escalated to the clinical governance committee if necessary. Board awareness of IPC incidents and themes was maintained through review of 12 months of IPC data.

Staff could access equipment and IT systems needed to do their work. Staff completed data security awareness training, with compliance recorded at 98.6%. New starters participated in a local induction session within their first month, which included a module on data security awareness. Information governance systems ensured confidentiality of patient records, and we observed secure storage of patient records was maintained.

The hospital had comprehensive policies and guidelines to support escalation and major incident management. The hospital risk management framework was overseen by the Ramsay Healthcare Risk Management Committee, which reported directly to the executive team.

Heads of department identified departmental risks, entered them on a departmental risk log, and escalated risk levels to the appropriate committee. Staff had access to the risk register, and local risk registers were displayed in clinical areas. Risks with a residual or current score between 1 and 8 were managed at departmental level.

The hospital risk register (updated 7 October 2025) identified six risks, which were reviewed monthly. Staff said they escalated concerns when required, and we observed staff concerns matched those on the risk register. Risks with a current or residual score ranging from 15 to 25 were classified as extreme and documented on the corporate risk register, then escalated to the appropriate governance committee for further review. The hospital identified two high risks (scored 20): the main hospital roof leaking and the nurse call bell system not linked to the pager system. The roof was upgraded during the assessment, and the call bell system was scheduled for replacement, with the installation date to be confirmed.

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.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders engaged effectively with external stakeholders, including commissioners, the local Integrated Care Board (ICB), the local authority, and the local NHS Trust. Quarterly meetings with the ICB took place where information was shared. Patients and staff had opportunities to meet with members of the provider’s senior leadership team and commissioners to provide feedback.

The hospital supported sustainability in healthcare through donations of recycled walking aids via Ramsay Health Care UK's partnership with another UK provider. Equipment was sent to a school in India, supporting children and adults with disabilities across nine centres. The consignment included 150 pieces of specialist paediatric equipment and 618 essential items, helping people regain independence and access vital care.

Clifton Park Hospital supported sport and local education by sponsoring several sports teams, promoting physical activity and positive local impact. Support was also given to local schools; one example included sending a group of students on an exhibition to Morocco, providing young people with the opportunity to experience a new culture and contribute to community projects overseas.

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.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

To support wider access to treatment within the local healthcare community and in collaboration with the local NHS Trust, Clifton Park Hospital (CPH), part of Ramsay Health Care UK (RHC), implemented an in sourcing initiative to deliver the local NHS Trust’s elective waiting list through the development of an ‘elective hub’ on the CPH site. This provided local patients with equitable, timely access to NHS orthopaedic care. The initiative was nominated for the HSJ Awards in the category of Best In sourcing Initiative by an Independent Health Care Provider.

The service involved patients and carers in shaping service development through structured initiatives such as PLACE audits and Patient Participation Groups (PPGs). In addition, the hospital piloted the Walk with Me patient experience project.

The Walk with Me project aimed to improve patient experience and build safer care using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. The programme engaged clinicians in continuous quality improvement and helped identify key facilitators and barriers to patient safety within the hospital. This initiative was presented nationally alongside other Ramsay hospitals. The first staff member to participate was the Hospital Director.

Walk with Me was designed to observe the patient’s surgical journey through the patient’s eyes and create a system where staff could view different areas and departments and suggest improvements. Staff shadowed patients through their day of surgery, making notes of patients’ emotions at each touch-point using a standardised template. After shadowing, staff debriefed with the quality improvement manager using SEIPS to analyse what worked well and what could be improved. Initial findings identified areas where patients required further support and noted that anaesthetic and ward rooms looked tired. Recommendations included using Walk with Me to review pre-operative, pre-assessment, and post-operative clinic follow-up pathways.

The hospital also piloted Sip till Send, a collaboration between ward staff and a consultant anaesthetist. Patients were informed of the trial and invited to participate, with risks and benefits explained. The pilot addressed the negative impact of prolonged fasting times prior to surgery, allowing patients to sip small volumes of clear fluids (water) while waiting for surgery. This maintained hydration and reduced risks of complications. The pilot was successful, became common practice, and was rolled out across all Ramsay sites.

As part of a work stream to improve implant storage safety, an issue was identified regarding the storage of Zimmer Biomet Persona knee articular spacers prosthesis, which highlighted a potential risk of incorrect prosthesis choice. Key findings from the never event informed quality improvement and safety innovations. Following this, staff engagement initiatives and improvement measures were implemented to enhance safety and reduce recurrence risk.

In April 2025, catering services were awarded a five-star rating following an environmental health assessment.

In 2024, Clifton Park Hospital successfully gained Bronze Aseptic Non-Touch Technique (ANTT) accreditation, with over 60% of clinical staff competency assessed.

The hospital successfully implemented the Patient Safety Incident Response Framework (PSIRF) into investigations of surgical site infections. Staff had completed training in the PSIRF methodology.