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During a routine inspection

Inspection carried out on 25 and 26 April 2017

During a routine inspection

Chase Lodge Hospital is operated by Chase Lodge Health Limited. It is an independent hospital in Mill Hill London. The hospital is primarily a GP service and offers imaging and diagnostic services. There is also a site pharmacy. 

Chase Lodge Health opened in 2007. The hospital has had a registered manager, Sarah Lotzof, in post since October 2010.

Chase Lodge Health Limited at the time of the inspection was registered to provide following regulated activities; diagnostic and screening procedures, personal care, surgical procedures, and treatment of disease, disorder or injury. As of June 2017 the provider removed personal care from their registration. The organisation provided services for children and adults of all ages.

The provider had agreements with other professionals who operated within the hospital; services included dentistry, psychology and osteopathy. This report refers only to services provided by Chase Lodge Health Limited.

We inspected Chase Lodge Health as part of our schedule for independent hospitals.

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.

We have not provided ratings for the service. CQC does not currently have a legal duty to award ratings for


cute non hospital services

. Amendment to the current Care Quality Commission (Reviews and Performance Assessment) Regulations 2014 is required to enable us to do this. In this report we highlight good practice and issues that service provider needs to address to improve the service as well as any regulatory actions necessary.

We said that the provider MUST take following actions in order to meet the regulations:

  • Ensure there is a robust governance structure in place to improve patient safety, learn from patients’ experience, and improve clinical effectiveness.

  • Ensure appropriate management of medicines including controlled drugs and administration of travel vaccinations

  • Ensure that appropriated recruitment checks are completed for all staff including appropriate checks through the Disclosure and Barring Service (DBS).

  • Ensure there is a radiation protection supervisor (RPS) which is a requirement of Regulation 17 of the Ionising Radiations Regulation 1999 (IRR99).

  • Ensure ionizing radiation is mea

    sured and monitoring instruments are fit for purpose.

  • Ensure medical records for all patients are maintained within the hospital. 

  • Ensure staff receives appropriate level of safeguarding training as required by current guidance.

We also said the provider SHOULD:

  • Ensure that policies are reviewed regularly and version control system is implemented.

  • Ensure that clinical waste is managed safely.

  • Ensure the environment, including the radiators, is assessed to prevent risk of harm to children.

  • Ensure that GP’s undertake mandatory training and that record of staff training is maintained.

  • Ensure all staff, including medical staff working under practicing privileges, are appraised and record of it is maintained.

  • Ensure there is an effective system to communicate with NHS GP’s about the management of patients with long term conditions.

  • Ensure there is an up to date policy for Deprivation of Liberty Safeguards and that staff receive training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards.

  • Endeavour to improve the patient satisfaction survey response rate.

Professor Edward Baker

Deputy Chief Inspector of Hospitals

Inspection carried out on 16 January 2014

During a routine inspection

All the people we spoke with were positive about the service. One person said, �it�s very good.� A second person described the service as, �quick and efficient.� Others referred to �caring� staff and �useful� that a range of services were provided on site.

People told us that they were involved in their treatment and provided with information. One person said, �they have given me useful information.� Care records were securely kept on the provider�s computer system. There was a dedicated computer software system which made it easy to retrieve information.

The premises, including the various treatment rooms, were clean. None of the people we spoke with had concerns about cleanliness. We saw that there were protective gloves and clothing available, cleaning protocols in place and suitable arrangements for disposal of clinical waste and sharps.

There were systems in place to make sure that visiting consultants had the relevant checks before they worked at the service. There were also systems in place to carry out recruitment checks for directly employed staff. An adjustment was needed to make these more streamlined. Staff reported being supported and we saw that staff worked well together. There was evidence that staff had received relevant training such as child protection and life support training.

There were a variety of systems in place to assess and monitor the quality of the service including regular clinical audits and ongoing surveys of people using the service. New policies and procedures were being introduced to the service with ongoing work to update risk assessments and staffing procedures.

Inspection carried out on 12 January 2012

During a routine inspection

Patients who used the service said that they felt listened to by medical staff and their privacy and dignity was always respected. Staff were described by patients as �careful and caring� and �kind�. One patient we spoke to told us he thought the service was �quite amazing� and that staff �went beyond the call of duty�. All treatment and procedures were explained to patients in a way they could understand. Referrals to specialists were made promptly and a range of tests including x-rays could be performed on site.

A number of medical practitioners and consultants provided services from Chase Lodge Health and had been granted practising privileges. However, documentation of current professional registration and criminal record bureau checks were not available for some staff. All staff granted practising privileges had been requested to provide up-to-date proof of registration and checks. The provider was in the process of following up those who had not responded adequately to the request.

Reports under our old system of regulation (including those from before CQC was created)