Baddow Hospital in Great Baddow, Chelmsford is a Clinic specialising in the provision of services relating to caring for adults over 65 yrs, caring for adults under 65 yrs, caring for children (0 - 18yrs), diagnostic and screening procedures, family planning services, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 12th June 2017
Baddow Hospital is managed by Baddow Hospital Company Limited.
Contact Details:
Address:
Baddow Hospital West Hanningfield Road Great Baddow Chelmsford CM2 8HN United Kingdom
Baddow Hospital is operated by Baddow Hospital Company Limited. The hospital comprises one ward with eight day case beds, five outpatient consultation rooms, two en-suite bedrooms for day case or overnight patients, two theatres, one pain management room, two treatment rooms and one ultrasound room.
The hospital provides surgery, and outpatients and diagnostic imaging services, both for patients over 18 years of age. We inspected both of these services. We carried out an announced inspection on 3 April 2017.
We last inspected Baddow Hospital in September 2016 where it was rated inadequate. This was based on findings including (but not limited to) a lack of formalised sharing learning from incidents; lack of a risk register and suitable governance processes; lack of a performance dashboard to monitor safety and quality; and a failure to meet national standards for safeguarding. Following this inspection, we issued a warning notice because the service was not meeting its legal requirements under Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also issued a requirement notice under Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The primary focus of this comprehensive re-inspection was to check whether the service was now compliant with these Regulations, although we covered all domains as outlined in the report, using our comprehensive inspection methodology.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.
Services we rate
We rated this hospital as good overall.
We rated surgery as good because:
Staff were familiar with the incident reporting system, and actions and learning from incidents were documented and discussed at the relevant meeting such as clinical governance meetings and then shared with staff.
The service had implemented a performance dashboard following our previous inspection to give an overview of safety, quality and risk. This included, for example, confirmation of the daily trolley checks, and the patient to staff ratio.
All equipment we checked was properly stored and in date, including within servicing date for electrical equipment.
Safeguarding training and procedures were in line with national guidance.
The admission criteria had been updated since our last inspection, primarily to exclude patients under the age of 18, to ensure the service was only admitting patients for whom it could provide safe care.
Nursing and medical staffing levels were both sufficient to safely meet the needs of patients.
Policies were up-to-date, based on national guidance and best practice and legislation, for example the safeguarding policy. Staff were updated on any policy changes and knew how to access policies.
Following our previous inspection, the service had implemented a comprehensive local audit programme and started participating in national audits, namely the Patient Reported Outcome Measures (PROMS) and the Breast Implant Registry, in order to benchmark and monitor performance.
There were opportunities for staff to undertake additional training or courses to develop their competencies.
Since our previous inspection, the service had updated their training programme to include comprehensive training on the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff showed good awareness of MCA and DoLS.
Staff displayed a caring approach and maintained patients’ privacy and dignity, for example by using retractable screens to section off patient areas.
Services were planned and delivered to meet patients’ needs. For example, there was a daily briefing where staff went through the plan for the day to ensure they could deliver services in a timely manner.
Translation services were available for staff to access for patients whose first language was not English.
The service had made significant improvements since our previous inspection (for example around governance processes, audits and safeguarding) and was now focusing on embedding these changes.
The service had implemented an appropriate risk register since our previous inspection. There was a nominated lead who had overall responsibility for monitoring risks on the register. All staff had access to the register and were encouraged to record any risks or incidents of any type.
Service leads had identified an area for improvement around information governance, as this was a recurring issue on the risk/incident register. The service had implemented additional training for staff to address their information governance concerns and senior staff told us they were beginning to see a culture change around better information governance.
Service leads had focused on implementing and encouraging a positive change in culture around the areas of concern we had identified from our last inspection. For example, staff were encouraged in team meetings to take an active role in the new combined risk and incident register.
However, we also found the following areas for improvement:
There was no clear, structured strategy to achieve corporate objectives within a set timeframe, although we understood that the hospital’s main focus had been addressing the areas of concern we had found on our previous inspection. This was detailed in their hospital improvement plan.
When we inspected, records for appointments on the same day were not locked within the reception area, although they were out of sight and out of general thoroughfares so only staff would have been able to see and access them.
Theatre team meeting minutes from March 2017 noted that morale was low and this was in part owing to recent redundancies. There was nothing in these minutes to say what managers were doing to boost morale.
Following this inspection, we told the provider that it should make certain improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.
Baddow Hospital is a privately run hospital on the South Eastern Healthcare Park two miles south west of Chelmsford City in Essex. The South Eastern Healthcare Park has planning permission for a total of four healthcare related service buildings, including Baddow Hospital which opened in June 2013 for private healthcare treatment after two years of extensive construction and remodelling.
The Care Quality Commission (CQC) carried out a comprehensive inspection on 04 November 2014. The reason for undertaking this scheduled inspection was to assess this private hospital to determine if all essential standards are being met. The hospital opened in June 2013. There were two identified risk areas which required follow up, these were the number of changes to the registered manager and a lack of a controlled drugs accounting officer.
For the purpose of the comprehensive inspection we undertook an on-site review of surgery and outpatient services. The on-site element of the inspection involved a team of experts by experience (service users), clinical associates (experienced healthcare professionals) and CQC inspectors. The team is divided into subteams, each of which looked at one the service lines described above. The subteams were led by an experienced inspector, supported by clinical experts.
Prior to the CQC on-site inspection, the CQC considered a range of information including information held within CQC and that provided by the provider.
The inspection team make an evidenced judgment on five domains to ascertain if services are:
Safe
Effective
Caring
Responsive
Well-led.
Our key findings were as follows:
Caring and compassionate care was evident in all areas.
Those patients who we received feedback from were very complimentary about the service they received.
There was a registered manager and accountable officer in place.
Staffing levels exceeded the safe staff level guidelines with the support of bank and agency staff.
The service had a robust process for appointing medical staff to the service with practicing privileges.
The hospital was visibly clean and good systems and processes for infection prevention and control were in place.
The service benefited from a very committed and loyal workforce.
The governance and management arrangements were in their infancy and were not robust.
We found that the facilities and equipment provided for this service were outstanding in relation because they were state of the art, modern and met patient’s needs.
We also found that there were areas where the provider needs to make improvements:
The provider should provide induction to all medical, bank and agency staff.
The provider should ensure that all staff training competencies on equipment and clinical observations are checked, monitored and up to date.
The provider should provide all staff with meetings to discuss the clinical services. These minutes should be recorded.
The provider should ensure that management support and oversight of theatres is provided by the registered manager.
The provider should develop and embed the governance systems further to ensure that they are robust.
The provider should ensure the accurate recording and reconciliation of controlled drugs be maintained.
The provider should ensure that risk assessments are undertaken as appropriate.
Baddow Hospital is operated by Baddow Hospital Company Limited. The hospital provides surgery and outpatient services. We inspected both these services.
The service provided outpatient and surgery to a small number of children and young people under the age of 18 years. Due to the small numbers of children and young people who attended the service we have not rated or reported on children and young people’s services, but included this in the reports for outpatients and surgery. Following our inspection the provider amended their statement of purpose on a voluntary basis to state that with immediate effect they would no longer see or treat any patient under the age of 18 years at the service.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 5 September 2016, along with an unannounced visit to the hospital on 19 September 2016. The hospital was first inspected, but not rated, in 2014.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.
Services we rate
We rated this hospital as inadequate overall. Surgery was rated as inadequate and outpatients was rated as requires improvement.
In surgery we found:
Staff we spoke with were not aware of any recent incidents reported by the surgical service or of any lessons learnt.
There were two leads for safeguarding children and adults and neither were registered professionals nor trained in line with national guidance. They were also unable to demonstrate sufficient knowledge about safeguarding.
Staff we spoke with were not familiar with the terms Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act 2005.
At the time of our inspection, there was no specific training on Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We were not assured that staff would be confident in dealing with potential cases involving MCA and DoLS.
There was no reference to Gillick competence or Fraser guidelines in the service policies on consent to treatment. There were no audits on Gillick or Fraser in the service.
There were no records kept for the checking history of the difficult airway and spinal equipment trolleys.
The service did not use a performance dashboard.
There was no participation in national audits, and oversight and analysis of local audit was limited.
Staff we spoke with confirmed they had not received training on dementia or learning disability, whilst at the same time confirmed that patients living with these conditions accessed the hospital.
The hospital did not have a risk register detailing risks known for patient safety, business continuity or any other service related risk.
Staff nurse appraisal rates in surgery were low.
The governance process was not effective and did not identify or manage risks effectively. The service was not aware of many of the risks identified throughout our inspection, such as safeguarding training and policies on consent.
The concerns identified with the lacking governance process were similar to those identified at the last inspection in 2014.
However there were some areas of good practice including:
There were reliable systems in place to prevent and control infection and we observed staff following infection control principles.
Medicines were regularly checked, stored safely, and prescribed and administered appropriately.
People’s healthcare records were legible, up to date and stored securely.
One-hundred per cent of staff had completed their mandatory training.
Risk assessments were carried out for individual patient risks relating to treatment. Procedures were in place for the assessing and responding to patient risk.
A sufficient number of suitably qualified staff was on duty at all times.
Pain was assessed and managed appropriately.
Multidisciplinary team working within the hospital and externally was effective.
Access and flow through the service was seamless, and admission times were flexible dependent on patient request.
Numbers of cancelled operations were low.
Within outpatients we found:
There were two leads for safeguarding children and adults and neither were registered professionals nor trained to expected levels as per national guidance. They were also unable to demonstrate sufficient knowledge about safeguarding.
Methicillin-Resistant Staphylococcus Aureus (MRSA) screening rates were low (between 19% and 50% for the period January to June 2016).
At the time of our inspection, there was no specific training on Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We were not assured that staff would be confident in dealing with potential cases involving MCA and DoLS.
Staff we spoke with confirmed they had not received training on dementia or learning disability, whilst at the same time confirmed that patients living with these conditions accessed the hospital.
There was no reference to Gillick competence or Fraser guidelines in the service policies on consent to treatment. There were no audits on Gillick or Fraser in the service.
The hospital was unable to provide exact data on referral to treatment times (RTT) but were able to demonstrate that they had never breached contractual waiting times for any NHS patients.
However, there were some areas of good practice including:
All areas we inspected were visibly clean and well laid-out.
All outpatient records we reviewed were clear and complete and records were stored securely, including within the consultation room.
Nurse and medical staffing levels were sufficient to meet patient needs and all medical staff employed under practising privileges were up-to-date with revalidation.
Staff were engaged through regular team meetings at a local level within outpatients and the administration team, and also through hospital wide communications.
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