The Care Quality Commission
  • Mental Health
  • Independent mental health service

Baldock Manor

Overall: Requires improvement read more about inspection ratings

4 London Road, Baldock, Hertfordshire, SG7 6ND (01462) 491951

Provided and run by:
Nouvita Limited

All Inspections

23-24 May 2023

During a routine inspection

Our rating of this location stayed the same. We rated it as requires improvement because:

  • Staff on Radley ward undertook long periods of enhanced observations without breaks. This does not adhere to guidelines by the National Institute for Health and Care Excellence. Staff completing extended periods of enhanced observations may be less likely to maintain the levels of concentration required to maintain patient safety and therapeutic engagement.
  • Radley ward had some blanket restrictions in place, including access to fresh air and water without staff assistance.
  • Staff on Radley ward described using incorrect restraint techniques.
  • Patients on Radley ward reported staff not being interested or helpful, particularly agency staff. We observed staff arguing in front of patients and discussing patients in front of them.
  • Patients told us the food was not of a good standard.
  • Staff did not provide patients with a copy of their care plan.

However:

  • Staffing levels had significantly improved since the last inspection and managers used bank staff wherever possible to fill vacant shifts.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

19 to 21 November 2019

During an inspection looking at part of the service

Baldock Manor is an independent hospital that provides a rehabilitation and intensive care service, to people who have needs related to their mental health and who are detained under the Mental Health Act 1983, Mental Capacity Act 2005, or are voluntarily staying at the hospital.

Following our inspection, we served a Notice of Decision because of the immediate concerns we had about that safety of patients. We told the provider it must not admit any further patients until further notice, it must review care plans, observation levels for patients, incidents, its systems and process for oversight of incidents and care, ensure it had enough suitably qualified, experienced staff on all shifts and that staff had adequate knowledge about the use of the Mental Capacity Act. We told it that it must provide CQC with an update relating to these issues on a weekly basis.

The provider has complied with these requirements. All patient care plans and observations have been reviewed and systems and processes are now in place for their ongoing review. The provider has reviewed its incident reporting system and process for the review of incidents. Notifications to external bodies have been made as required. Staff have been tested for competencies around patient observations, diabetes, choking and the Mental Capacity Act. The provider has produced weekly staffing figures, which have confirmed that most shifts have been covered.

We rated Baldock Manor as Requires Improvement because:

  • The number of incidents for the provider had increased between September and October 2019. Staff across both wards reported 131 incidents in October 2019. Leaders had not always ensured that all incidents had been reported and that referrals had been made to external bodies as required. The provider had not reported all incidents that required a safeguarding notification and had not made notifications to external bodies including local authorities and the Care Quality Commission as required.
  • The provider had a 75% vacancy rate for qualified staff to lead and manage care and a 21% vacancy rate for support workers. We heard how staffing issues adversely affected patient care. Whilst agency staff were provided with an induction, during inspection some staff did not have a full understanding of patients’ risks or care planned needs.
  • Whilst we accept that managers had updated the ligature assessments for the wards, these were not available to staff.
  • There were several restrictive practices in place. Patients on Radley and Mulberry did not always have free access to outside space and fresh air. Patients on Radley only had access to cold, hot drinks and snacks on request to staff over the 24-hour period.
  • Leaders had not always ensured that services were safe, clean and well maintained.
  • Staff were not all aware of the identified ligature points or how to manage these risks.
  • Staff were not fully adhering to infection control requirements. Staff were wearing nail varnish, were not bare from the elbow and were wearing jackets on the ward when completing personal care tasks with patients.
  • Some staff did not display a good understanding of the Mental Capacity Act and the provider cared for patients who lacked capacity to make decisions. Staff did not know how to apply the main principles to their work.
  • The provider did not ensure that training in the Mental Health Act or safeguarding children was mandatory.
  • Although managers at the hospital were fully committed to the service they were not fully aware of all aspects of their roles and did not have the knowledge or skills to run the service effectively.
  • The provider had not fully ensured that effective governance systems were in place. The provider did not have an effective system to oversee and assure itself of the quality of the services and ensure patients were kept safe and received good quality care.
  • The provider did not have a clear model for the rehabilitation service. This service was supporting people with dementia which was not appropriate.
  • Managers did not have immediate access to business information relating to staffing, patient observations, incidents, safeguarding referrals and notifications to support them to carry out their role. Leaders could not clearly explain how the teams were working to provide high quality care.
  • Ward areas and patient bedrooms were sparse, and patients on Radley did not have access to alarms.
  • There was little evidence of rooms being personalised. Not all care plans were comprehensive or met the needs identified during assessment.
  • Care plans were not always recovery-orientated or written from the patient’s perspective. There were no best interest assessments to support the care plans written in the third person.
  • The information shared at handovers was not always understood by staff.
  • Patients and carers interviewed stated that staff did not always communicate with patients, families and carers so that they understood their care and treatment. Patients and carers told us that staff did not fully inform and involve all families and carers.

However:

  • There had been a reduction in seclusions and an overall reduction in patient restraints.
  • The provider delivered mandatory training for all staff. The majority of staff had completed their mandatory training (99%). Staff had the required mandatory skills and knowledge to meet the needs of the patient group.
  • Staff had access to regular supervision and appraisal.
  • Staff had completed comprehensive mental health assessments and risk assessment for patients. Staff used recognised rating scales to assess and record severity and outcomes.
  • When interacting with patients, staff attitudes and behaviours generally showed that they were discreet, respectful and responsive. Patients said staff treated them well and behaved appropriately towards them.
  • Staff had enabled patients to give feedback on the service they received and ensured that patients could access advocacy.
  • Staff supported patients during referrals and transfers between services, and supported patients to maintain contact with their families and carers.
  • Staff described an improvement in the culture of the hospital. Staff felt respected, supported and valued. Leaders were very visible in the service, were approachable for patients and staff.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

2nd and 3rd October 2018

During a routine inspection

We rated Baldock Manor as requires improvement because:

  • The level of patient need on Burberry Ward exceeded the number of registered staff available to deliver interventions.
  • The seclusion room did not comply with Mental Health Act guidance due to blind spots both in the seclusion room and in the ensuite toilet.
  • The ward was not in line with mixed sex guidance due to the lack of a female lounge on Burberry Ward.
  • On Radley Ward, patients did not have access to drinks 24/7 and were unable to access a remote for their televisions. Staff had not individually risk assessed either of these in patient records.
  • The filing of patient records was not always carried out correctly. Staff had uploaded some patient records into the wrong patient record.
  • The community meeting on Burberry ward did not have a formal agenda and did not always start on time.
  • There was limited evidence of statutory consultation with family and carers in relation to the Mental Capacity Act.

However:

  • Staff rarely cancelled escorted leave due to staffing shortages. There were effective working relationships between teams and effective multidisciplinary meetings.
  • Managers had completed risk assessments on both wards. The wards were clean, presentable and well maintained.
  • Compliance with mandatory training was 95%. Staff were trained in safeguarding and knew how to make a safeguarding alert.
  • Staff completed comprehensive and timely assessments for all patients on admission. We saw evidence that staff involved patients in care planning. There was a wide range of psychological therapies available to patients.
  • There was good access to physical healthcare. Staff met patient’s physical health needs and monitored these regularly.
  • Staff were aware of what incidents to report and the process of how to report them. The process for staff to learn from incidents, complaints and service user feedback was robust.
  • Staff carried out regular audits to ensure the Mental Health Act and Mental Capacity Act were correctly applied.
  • All staff received appraisals annually.
  • We saw positive, caring interactions between staff and patients during our inspection.

21-23 February 2017

During an inspection looking at part of the service

We rated Baldock Manor as requires improvement because:

  • Male patients were permitted to spend periods of time on Oakley female wards. There was no evidence of risk assessment or care planning to safeguard those patients.
  • Risk assessments did not always capture recent changes in risk following update.
  • The service had 27 staff vacancies and staff turnover was at 33%.
  • Qualified staff were not visible on all wards and some worked across two or three wards.
  • There was little evidence that patients were having 1:1 time with their named nurse.
  • Not all patients were being offered regular Section 17 leave. Not all patients were having regular access to outside spaces for fresh air.
  • Checks of physical health equipment including emergency equipment were not taking place.
  • Incident reports were not always fully completed.
  • Confidential information was not always stored securely on all wards.
  • Care plans were not always personalised or person centred.
  • There was a lack of psychological therapies in place across the service.
  • Mental Capacity assessments were not robustly completed.
  • We were not assured that patient’s dignity was maintained on Oakley female ward.
  • There was little evidence of therapeutic activities on the wards.
  • Most ward based staff were not aware of lessons learnt following investigation and complaints.
  • Managers did not provide staff with regular supervision and annual appraisals.
  • There was a high dependency of bank and agency staff.
  • Ward based staff were not aware of the organisations visions and values.

However:

  • Managers completed regular ligature audits.
  • All ward environments were clean and tidy and well maintained with adequate equipment to support treatment and care of patients.
  • Staff compliance with mandatory training was at 94%.Overall, 96% of staff had received training in the Mental Capacity Act and 91% of staff had received training in the Mental Health Act.
  • We observed staff interact with patients in a caring and respectful manner. Staff understood patient’s individual care and treatment needs.
  • There was access to an advocacy service.
  • We saw evidence of a variety of meal options provided by the kitchen.
  • Information was available to patients on treatment, advocacy and their rights.
  • Patients could personalise their bedrooms should they wish to.
  • Overall sickness was at 3.7 %.
  • There were no reported cases of bullying or harassment.
  • Staff generally felt listened to and supported.
  • Senior managers were visible and available to staff.

24, 25 May 2016

During an inspection looking at part of the service

This inspection was carried out to follow up and review action taken by the provider against warning notices issued following an inspection in November 2015.

At this inspection of May 2016 we found:

  • Staff had not completed in full or regularly updated eight out of 15 risk assessments.
  • Electronic incident reports were not fully completed. Incidents had taken place but staff had not recorded them in patients’ case notes or completed incident forms in all cases.
  • Staff did not keep up to date records to ensure that they were monitoring incidents, lessons learnt and outcomes. Managers did not review, record actions taken or outcomes for patients on the majority of incident forms.
  • There had been 24 safeguarding incidents, of which 18 had not been notified to the CQC. Senior managers did not have robust monitoring systems in place for monitoring the outcomes of safeguarding incidents and to ensure that external agencies were notified in a timely way.
  • Staff and patients had used furniture to prop doors open on all wards across the service. The propping open of doors was in breach of both health and safety, and fire regulations.
  • The provider had installed mirrors to mitigate risk where some blind spots had been identified. However, this did not mitigate risk in some areas due to their position.
  • We found the emergency bag on Mulberry ward had a pulse oximeter without batteries from 09 September 2015 to 01 May 2016.
  • Staff did not have access to the correct clinical waste products and had not followed infection control principles when discarding clinical waste. Staff had not completed handwashing training for 12 months.
  • There had been some improvement to staff training. However, only 62% of staff had completed mandatory training and 70% completed refresher training. The provider had an action plan in place to improve compliance with mandatory training.
  • Monthly meetings took place to discuss service wide improvements. However, actions identified as required were not all undertaken. It was also not clear that the learning from these meetings was shared across the service.

However:

  • The majority of care plans were fully completed and reviewed regularly.
  • Staff ensured the patient’s physical health was monitored regularly. This included blood tests and electrocardiograms.
  • Staff monitored and recorded patients fluid intake when required to ensure they were receiving the recommended daily allowance. The multidisciplinary team and dietitian reviewed fluid charts regularly.
  • Staff were not using restrictive practices to manage the risks of the patients.
  • Managers completed comprehensive ligature and environmental risk assessments for all wards and these were up to date.
  • The hospital was now compliant with guidance on same sex accommodation.
  • The provider had systems in place to ensure that agency staff were appropriately trained prior to working with patients.
  • Complaints were investigated and outcomes and lesson learnt were shared with the complainant and discussed in monthly meetings.
  • Activity rooms were available across the service that were equipped with games and activities.

3,4,12,13,18 November 2015

During a routine inspection

We rated Baldock Manor as inadequate because:

  • Risk assessments lacked detail, were not fully completed, and did not include details of how staff would manage or mitigate risk.
  • Care plans were generic and were not person centred, specific, measurable, achievable, relevant, or timely in line with guidance. Staff did not review care plans regularly or document changes in patient’s progress or deterioration.
  • Staff regularly used seclusion and restrictive interventions, senior staff did not identify that these practices were in use or record these as an incident or a safeguarding issue. We asked for information on seclusion and restraint before the inspection but managers did not provide this.
  • Electronic incident reports were not fully completed. Incidents had taken place but staff had not recorded them in patients’ case notes. When senior managers investigated serious incidents, they did not identify lessons learnt to minimise the risk of repeated incidents.
  • Staff did not store, dispense, or administer medications in line with legislation and guidance.
  • The lay out of the wards meant staff could not guarantee quick access to the emergency equipment.
  • Staff did not assess the physical health needs of patients fully. They did not always monitor patients’ blood for diabetes nor did they follow up abnormal blood test results. The fluid charts that staff completed showed eight patients’ intake was below the recommended daily amount.
  • Staff did not always provide care that was compassionate. For example, they left patients in protective clothing outside of meal times. During our visit, one patient did not have breakfast because there were too few staff on duty to assist them out of bed. Two patients told us that sometimes staff had arguments in front of them and did not always speak English on the wards.
  • One ward did not promote comfort or dignity. There was only enough space for two patients to eat at a table, meaning the other patients had to eat their meals off a tray on their laps. Another ward compromised patient dignity and privacy because of glass panels in interlocking doors between a female and male ward and bedrooms.
  • Patients with mobility problems could not access two garden areas due to steep steps although other areas were provided at the front of the hospital.
  • The service had high vacancies and relied on agency staff. They did not hold accurate records for permanent staff or do full checks on agency staff. This all affected patient outcomes.
  • 62% of staff had completed mandatory training.
  • The layout of the service meant all wards had blind spots, so staff could not fully observe patients.
  • Oakley ward did not comply with the Department of Health’s guidance on same sex accommodation.
  • Staff did not routinely carry out environmental audits.
  • The provider could not give example of how audits, which clinical staff participated in, had led to improvements in the service.
  • Staff did not receive specific training the Mental Health Act or undertake regular audits to ensure that they applied the MHA correctly.
  • Fifty eight percent of staff had training in MCA. Staff did not assess individual capacity in relation to medical interventions.
  • The procedure for patients to make complaints was not robust, efficient, or accurate.
  • The provider did not operate an effective system to monitor or improve the quality of the service. The provider did not use key performance indicator and other indicators to measure the performance of the service.

However:

  • All staff received supervision and 81% of staff had received training in Deprivation of Liberty Safeguards and Code of Practice changes.
  • Patients had access to an independent mental health advocate. All wards and the reception area had information on treatments, local services, patient rights, and how to complain.
  • From the interactions we observed, staff interacted with patients in a caring and respectful manner. When patients were admitted to the service staff showed patients around and introduced them to other staff and patients.
  • The kitchen provided a wide choice of meals for patients and this choice extended to catering for specific dietary requirements.
  • Staff and patients told us that senior managers were approachable and visible to staff and patients. There were no reported bullying and harassment cases.
  • Staff told us that morale on the wards was good. They reported that there was a good skill mix and staff worked together as a team.

During a check to make sure that the improvements required had been made

We found that the provider had taken suitable action since the last inspection to ensure that medication was being safely managed and accurately recorded when administered to people. New protocols had been put in place to ensure that regular audits would be used to check the accuracy of the records for medication that had been administered to people.

22 August 2013

During a routine inspection

During the inspection we spoke with five people who were receiving treatment at Baldock Manor. The comments people made about their care and treatment were positive. One person told us about a less than positive experience, of which we informed the registered manager.

One person said, “The staff speak to me and treat me as an equal and are polite". Another person said, "I am happy to be here as I know that this is the right place to be but I eventually want to move away and live independently. They are helping me to achieve this, and they know all about my intentions, which have been discussed at the meetings I have with the doctors and nursing support staff".

We found that the medication records used by Baldock Manor for administering medicines to people were in need of improvement, to ensure that they were accurate records of what amounts of medicines were being stored at the hospital.

Staffing levels and staff competencies were sufficient to meet people’s assessed needs.

The hospital's complaints system and associated records were robust. We saw that complaints had been managed in an open approach and that complaints made to the hospital had been appropriately responded to. These had also included external organisations and local communities in the process to resolve issues.