Source · CQC inspection

Frimley Park Hospital

Provider Frimley Health NHS Foundation Trust Type NHS Healthcare Organisation Region South East Last inspected 28 Aug 2025

Overall rating: Good  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Outstanding
Responsive
Outstanding
Well-led
Outstanding

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 28 August 2025
The service is performing well and meeting our expectations.
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 …

Ratings by service

Medical care (Including older people's care)
Outstanding
Feb 2025
Urgent and emergency services
Good
Feb 2025
Medical care (Including older people's care)
Outstanding
Jan 2025
Urgent and emergency services
Good
Jan 2025

Earlier inspection findings

pre-2024 framework · 3 must-do 9 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3
Must do
Safe
The service must ensure all staff have completed mandatory training.
Regulation: Reg12
⚠ The service provided mandatory training in key skills to all staff however, not everyone completed it. Medical staff did not always receive or keep up-to-date with their mandatory training. Compliance rates for medical staff were below the trust target rate of 90% in 12 out of 24 modules including: blood …
Must-do action 2 of 3
Must do
Safe
The service must ensure that infection prevention and control measures are carried out effectively and the clinical environment and equipment is clean and fit for use.
Regulation: Reg12
⚠ Equipment and the premises was not always visibly clean. However, there were some areas where wards had failed cleaning, for example floors and low-level surfaces, and some dusty equipment was noted. On the day of inspection wards and general areas in the maternity unit were tidy and well maintained however, …
Must-do action 3 of 3
Must do
Safe
The service must ensure that medicines are checked and stored safely.
Regulation: Reg12
⚠ However, daily safety checks were sometimes missed, and there was out of date medicine. We found expired medicines including antibiotics, anti-coagulant injections, and emergency medicines for haemorrhage. During February and May 2023, 1 daily check for controlled drugs was not completed. However, there was no formal process of checking stock …

Should-do actions (9)

Recommended improvements to enhance service quality.

Should-do action 1 of 9
Should do
Safe
The service should ensure correct and effective use of MEOWS and NEWTT charts to accurately identify deteriorating patients.
Should-do action 2 of 9
Should do
Safe
The service should ensure safety huddles and handovers are conducted in a standardised way, in a suitable environment free from interruptions.
Should-do action 3 of 9
Should do
Safe
The service should ensure records are completed in full, and that effective audits take place using reliable data.
Should-do action 4 of 9
Should do
Well-led
The service should continue to ensure there is an accurate overview of risks faced, including how assurance is gained in the absence of a live maternity dashboard or ability to extract all suitable data from IT systems.
Should-do action 5 of 9
Should do
Well-led
The service should ensure all staff have annual appraisals.
Should-do action 6 of 9
Should do
Safe
The service should ensure incidents are graded appropriately.
Should-do action 7 of 9
Should do
Well-led
The service should ensure policies and guidelines are up-to-date, and that there are effective processes in place to manage them.
Should-do action 8 of 9
Should do
Safe
The service should consider the addition of a supernumerary co-ordinator to oversee staff and acuity across the whole maternity unit effectively.
Should-do action 9 of 9
Should do
Safe
The service should continue work on completing guidelines for maintaining safe levels of inhalational nitrous oxide on the maternity unit.

Location details

CQC ID: RDU01
Local authority: Surrey
Region: South East

Inspection report

Type: Location
Date: 13 September 2023
Rating: Outstanding
Actions: 3 must-do 9 should-do
AI-extracted 2 Jun 2026