Archived: Baddow Hospital Also known as Baddow Hospital Company Limited

Updated 12 June 2017

Baddow Hospital is operated by Baddow Hospital Company Limited. The hospital opened in 2013. It is a private hospital in Great Baddow, Essex. The hospital primarily serves the communities of the Chelmsford area.

Baddow Hospital treats patients funded by private medical insurance cover, self-funding or NHS outsourced patients. The specialities covered are general surgery, gynaecology, urology, dermatology, rheumatology, ENT (ear, nose and throat), pain management, maxillofacial, podiatry and foot and ankle surgery. The hospital also provides cosmetic surgery services; however, we do not currently have a legal duty to rate cosmetic surgery services.

The hospital has had a registered manager in post since October 2014.

Updated 12 June 2017

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.

Professor Edward Baker

Deputy Chief Inspector of Hospitals

Updated 12 June 2017

Surgery was the main activity of the hospital. Please see above for full summary.

We rated outpatients and diagnostic imaging as good.

• Outpatient consultation rooms were visibly clean and we saw staff compliance with infection prevention and control in outpatient areas..
• There was emergency equipment for outpatients including a defibrillator stored behind the main reception desk.
• Appointments were arranged at the convenience of the patient and ran in a timely manner.
• The service used a disability audit form which aimed to ensure the department was accessible to all. This included, but was not restricted to, factors such as appropriate seating in waiting areas, a lowered section of the reception desk and information tailored to specific needs.

Updated 12 June 2017

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

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.
• 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 patients’ needs.
• 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.
• 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 ’10 at 10’ meeting 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 we were told 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.