Frimley Park Hospital

Updated 28 August 2025

Date of assessment: 4 to 5 February 2025. Frimley Park Hospital provides a range of NHS hospital services. This assessment looked at urgent and emergency care services and medical care services. The rating from urgent and emergency care and medical care has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Frimley Park Hospital. Frimley Park Hospital has maintained the rating of Good overall.

We rated urgent and emergency care services as Good. In our assessment of urgent and emergency care services we found there was a positive learning safety culture. Risks to patient safety were mostly mitigated. Staff provided care and treatment following evidence-based practice. Staff treated patients with kindness, empathy and compassion and tried to ensure patients' dignity and respect was maintained. People could not always access care and treatment in the department in a timely manner due to flow issues throughout the hospital. There was strong leadership who embodied the culture of their workforce and developed a shared vision and values amongst all staff.

We rated medical care services as Outstanding. In our assessment of medical care services we found the service had a proactive and positive culture of safety. Staff delivered good care and treatment following evidence-based practice and people had good outcomes. The service was exceptional at treating people with kindness, empathy and compassion and in how they respected people's privacy and dignity. People could access care and treatment when they needed it. Leadership embodied the cultures and values of their workforce and empowered staff to lead change to improve the quality of service to patients.

Updated 11 February 2025

On Tuesday 4 and Wednesday 5 February 2025 we carried out an inspection at Frimley Park Hospital. This inspection was part of our System Pathway Pressures programme where we inspected Medical Care and the Emergency Department (ED). This report relates to the medical directorate at Frimley Park Hospital. The medical directorate consists of around 17 wards and departments. We went to most of these areas. We spoke with 15 patients and two relatives/carers.

We reviewed seven adult patient records. We spoke with more than 50 staff which included: consultants, resident doctors, nurses, senior leaders, healthcare assistants, administration staff, housekeeping staff and volunteers.

We assessed 24 quality statements across the safe, effective, caring, responsive and well-led key questions and we have combined the scores for these areas with scores from the last inspection to give the rating.

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. There were sufficient staff who listened to people's safety and individual needs. Systems and processes were in place to review the safety of care provided.

When the hospital was busy, leaders reviewed staffing levels to meet the needs of their patients. Staff delivered good care and treatment following evidence-based practice and people had good outcomes. The service monitored care outcomes and sought to improve, even when meeting national benchmarks.

The service was exceptional at treating people with kindness, empathy and compassion and in how they respected people's privacy and dignity. Staff always treated colleagues from other organisations with kindness and respect. The service was exceptional in how they listened to and understood people's needs, views and wishes. Staff responded to people's needs in the moment and acted to minimise any discomfort, concern or distress. The service always cared about and promoted the wellbeing of their staff and was exceptional at supporting and enabling staff to always deliver person-centred care.

People could access care and treatment when they needed it in a variety of ways. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service was aware of system pressures and sought to develop services that met the changing needs of patients.

The department and staff were well-led by strong leaders who embodied the cultures and values of their workforce. There was improved governance and risk management, and a positive culture. The service worked well with others in the Integrated Care Board to meet the needs of people. They empowered staff to lead change and improve the quality of service to patients.

Updated 11 February 2025

In our assessment of Urgent Emergency Care (UEC) services we found there was a positive learning safety culture where events were investigated, and learning was shared and embedded to promote good practice. Staff we spoke with were open and honest when things went wrong, and they had the opportunity to learn and gain experience. The environment was safe and well maintained. Staff practiced high standards of infection prevention and control. Risks to patient safety were mostly mitigated. There were effective mechanisms to adjust staffing levels when needed to keep the department and patients safe. Staff mostly demonstrated safe medicines management.

Staff provided care and treatment following evidence-based practice. Staff were trained and competent and had the right skills to meet patient’s needs. There were effective processes to ensure clinicians were available with paediatric competencies and qualifications to assess children who were streamed away from the adult emergency care setting to the Children’s emergency department (CED). The service monitored care outcomes and sought to improve.

Staff treated patients with kindness, empathy and compassion and tried to ensure their dignity and respect was maintained. Staff always treated each other with kindness and respect. The majority of patients were positive about the care they received. Leaders promoted and supported the wellbeing of staff.

People could not always access care and treatment in the department in a timely manner due to flow issues throughout the hospital. The service was aware of system pressures and sought to develop services that met the changing needs of patients.

The department and staff were well-led by strong leaders who embodied the cultures and values of their workforce. There was a shared vision and a set of values amongst all staff. There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system.

Updated 26 September 2014

Overall we rated the services for children and young people as good.  We found children’s services to be generally safe. However, we had concerns about nursing staffing levels and skill mix. For example, it had been identified as part of the annual clinical governance review that during periods of limited staffing, there had been an increase in medication incidents.

There were procedures in place to manage the deteriorating patient although the trust had identified that additional work was required to ensure that staff had the necessary skills to both identify and manage the deteriorating child.

Children’s services followed national evidence-based care and treatment and carried out local audit activity to ensure compliance.

Children and those close to them, such as their parents or carers, were involved in the planning of care and treatment and were able to make individual choices on the care they wished to receive. Leadership within the service was strong with a mostly cohesive culture. There was evidence of public and staff engagement as well as innovation within the service.

Services for children and young people followed the trust’s incident reporting system and demonstrated that learning from incidents that took place there. Perinatal and clinical governance meetings were held and staff were able to demonstrate that learning from these meetings was taking place.

The children and young people’s service was provided in a clean environment. Emergency equipment was checked in line with trust policy and was readily accessible and available.

Updated 26 September 2014

Overall we rated critical care services outstanding. Patients we spoke with told us of the “good reputation” the service had in the locality and also that they felt “very safe” when using its facilities.

Patients had access to a bereavement service and annual memorial service to remember their loved ones. The unit had implemented the use of patient diaries and a psychology service was provided. Relatives of patients who remained on the unit for more than one week had a meeting with the matron of their service to ensure any concerns they had would be addressed.

The unit delivered a consultant-led service with two consultants providing medical cover. One consultant was solely dedicated to being on the unit from 8am until 10pm daily. Another consultant provided support to the critical care outreach team and covered the unit on an on-call basis from 10pm until 8am. There were resident facilities provided for consultants who lived more than the recommended 30 minutes away from the hospital. There was nine hours of on-site consultant cover provided at weekends. The unit did not use locum doctors to cover unexpected vacancies. Medical oversight of the MADU was primarily by respiratory consultants with support from their intensive care colleagues when required.

Use of agency nursing staff was below the acceptable minimum rate set by the trust, and all agency staff were subject to a strict recruitment and induction process which mirrored the trust’s own recruitment policy. The unit had also rolled out an advanced Critical Care Practitioner training programme, one of very few nationally and the first regionally.

All aspects of care delivered in the unit were audited and reviewed to enable continuous improvements. The unit had implemented extra quality and safety measures to ensure it was delivering a high quality service in line with national guidance. The unit could demonstrate that it was achieving low mortality rates and good patient outcomes when compared to other units of a similar size. We found an open and transparent approach to incident management and a real focus on learning from these events through root cause analysis and peer review processes. There were continuous data submissions to national audits and participation in research programmes on the unit.

The unit was innovative. For example, it had implemented cardio pulmonary exercising testing and Intra-aortic balloon pumps. It regularly contributed to the CCN (Critical Care Network), RCN (Royal College of Nursing) and BACCU (British Association of Critical Care Units).

We found there was a real commitment to delivering multidisciplinary care and the nursing staff worked flexibly to ensure that a quality service could be delivered safely during busy times. Staff felt valued and supported by their teams and by senior management. They told us they received appropriate training to enable them to meet people’s individual care needs. Staff discussed the continuous learning culture on the unit and how they felt supported to engage in continuous personal development.

Staffing levels were continuously reviewed using the unit’s staffing acuity tool and we found the staffing levels to be adequate to deliver the service.

The environment was cleaned to a high standard and the trust’s infection control policy was being complied with. The unit demonstrated safe medication management and we saw adequate supplies of equipment to meet patients’ care needs.

Updated 26 September 2014

Overall we rated end of life care as outstanding.  We found that Frimley Park Hospital was providing an exemplary quality of care to people approaching the end of their life. The few areas where there was potential for improvement had been identified and we saw evidence that work was in progress to make the service even better.

The trust’s End of Life Care (EOLC) Steering Group, which was responsible for the overall monitoring of the provision of EOLC, was established in 2008. It had developed policies and procedures to support end of life care and had a diverse multi-disciplinary membership from both the trust and local community. The EOLC Steering Group was chaired by the Clinical Director for Surgical Services, which meant that the trust strategy for end of life care was disseminated well across all services and we found that there was good ‘buy in’ to the end of life policies from staff working outside the SPCT.

The hospital’s palliative care team saw approximately 1,028 patients in 2013/14. Of these, 51% were non- cancer patients, which showed a good balance between cancer and non-cancer patients being provided with the specialist services of the palliative care team. We were told that 45% of patients who died at the trust were referred to the specialist palliative care team, which compares well with the national average of fewer than 40%. Where people received specialist palliative care input, less than a quarter (23.9%) died in hospital compared to national data for all deaths that showed 51.5% of people died in hospital nationally. This means that the good access to the expertise of the SPCT, coupled with a robust discharge policy, allowed more people to die where they wanted and reduced both the length and frequency of admissions for end of life care.  The first national VOICES survey of the bereaved (2012) found that 71% of people wanted to die at home and the trust’s staff talked with enthusiasm about their proactive stance in getting people home to die if at all possible. This was supported by a strong rapid discharge policy that was sufficiently resourced to make it workable. A strong culture of enabling rapid discharge supports people and their families in their desire to die in their home surrounded by the people they love and within a familiar environment that they retain more control over. We were told that the shortest recorded discharge was just 45 minutes but that this was not the norm; a one-day target for making the necessary arrangements for a safe discharge was more usual.

The trust had implemented the AMBER care bundle system, which provided a systematic approach to manage the care of hospital patients who were facing an uncertain recovery and who are were at risk of dying in the next one to two months.

A review of the data showed that the trust had robust policies and monitoring systems in place to ensure that it delivered good end of life care. However, it was the direct observation and conversations with staff, relatives and patients that made us judge the care outstanding. Individual stories and observed interaction provided assurance that staff of all grades and disciplines were very committed to the proactive end of life care agenda set by the board. One healthcare support worker said, “Is it odd that I enjoy caring for people at the end? I don’t mean I want them to die, because I have usually got to know them and care about them and their families, but I am really proud of the good care we give and how comfortable we make people. It is nice knowing you couldn’t possibly do any more for them.”

A porter told us that all his team treated the people who had recently passed away on the wards as if they were “our own nan or mum. We make sure we look after their dignity and that they are comfortable. Most of us talk to them about where they are going and explain what the mortuary will be like and that their fridge will be cold. It makes our job better if we do it properly and kindly”.

We spoke with many people who were approaching the end of their life and some of their relatives. All were extremely positive about the care and support they received at Frimley Park Hospital. People told us their symptoms were very well managed and that nothing was too much trouble for staff. We observed kind and gentle interactions between staff and patients and could see that the people we visited in their rooms were clean, comfortable and hydrated. We sat with one elderly person who was being cared for in bed, in a single room, as they were expected to die shortly. This person slid their hand out of the covers to hold our hand and said they weren’t really frightened as everyone was so kind to them. They said their grandchildren had visited and bought them lovely presents that were displayed around the room. Then they showed us the bright nail polish that they said one of the night nurses had used when they gave them a manicure. They said, “I used to like dancing and parties and my nails make me smile and remember those days”.

We asked numerous staff about the care and support they received when people died. Many acknowledged that it could be emotionally difficult when caring for people in their last days and hours, but all said they had excellent support and told us who they could turn to at these times. Staff mentioned their teams supporting each other, approachable and supportive ward colleagues, input from clinical nurse specialists and senior managers and the chaplaincy team. One junior nurse told us about a recent traumatic death where she had been upset after caring for the patient. They said, “One of the consultants took me to the quiet room and sat with me for ages explaining why the person suffered the symptoms they did and that they would not have been aware of the symptoms. He spent ages answering all my questions and making sure I was OK”. Good staff support is essential to enable the staff to provide effective end of life care. Well cared-for staff meant that they felt strong enough to provide good care in difficult circumstances and we found that the good staff support available enabled them to provide effective end of life care.

Staff across the hospital were justifiably proud of the quality of end of life care they provided; all the staff smiled easily as they went about their work. They talked about, “Loving their work” and “Really enjoying caring for elderly people”. Senior managers were effusive in their praise of the whole staff group and this had enabled ownership of care quality by the whole hospital staff team.

Updated 13 September 2023

Updated 26 September 2014

Overall we rated outpatients as good.  Patients attending for outpatient appointments at Frimley Park Hospital and other clinic sites provided by the trust received good care. The premises were, with the exception of the fracture clinic, appropriate for the service they were providing. Where issues around capacity had been identified, the trust had responded to reduce the impact on patients.

We did identify some minor shortcomings in care practice by individual staff members, but this was not widespread.

Staff were kind, attentive and spent time ensuring patients understood what their appointment involved and what their treatment plan was. Where necessary, people were assisted to make follow-up appointments and to access the hospital transport.

The trust generally compared favourably with other trusts nationally in meeting waiting time and treatment targets, and in ophthalmology was a market leader, having been presented with an award as Clinical Service of the Year by the Macular Society. There was scope for a more consistent and sustained level of achievement in meeting targets and delivering an above average service.

Leadership at all levels was visible and engaged with operational staff. Staff reported feeling supported and encouraged to innovate. There was some uncertainty in response to our questions by the nurse in charge of the main outpatients department, but we accepted they had been thrust into the position by the death of a senior colleague a very short while before the inspection. The impact of the loss of a close colleague was clearly felt throughout the department but this did not impact significantly on the delivery of patient care.

The Head of Nursing for the outpatients department said, “We put patients first. We work as a team. The patient pathway through the outpatients department links with so many departments and we communicate well with them. We always look ahead and we always deliver a level of care we would expect our families to receive”.  Our observations found this to be true.

Updated 13 March 2019

Our rating of this service went down. We rated it as good because:

• Patients were assessed, treated and cared for in line with professional guidance. Staff completed risk assessments for clinical risks including falls, pressure ulcers and venous thromboembolism (VTE).
• We observed multidisciplinary participation in all patient care. Patient records demonstrated input from allied health professionals, medical and nursing staff. All staff spoke of good working relationships.
• Staff understood their responsibilities to report incidents, including safeguarding concerns. We saw staff received feedback and lessons learned were shared.
• Local governance arrangements were robust, and the service leaders were aware of the risks to their service. The concerns staff told us about, were reflected in the risk register.
• There was a clear leadership structure and strategy for surgical services. Staff told us that leaders were visible, approachable and supportive.

However:

• During our inspection we found access to store rooms was not correctly restricted, allowing access to unauthorised persons.