Baldock Manor

Updated 16 September 2025

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question as good. At this inspection, the rating has remained as good. This meant people were safe and protected from avoidable harm.

Staff had a good understanding of learning from incidents and were able to give us relevant examples of lessons learnt following incidents.

The care environment was safe, clean and well- maintained. 

Staff completed comprehensive care plans of patient needs that were detailed, personalised, holistic, recovery-oriented and included patients views.

Staff treated patients with kindness, empathy and compassion.

The service ensured they met the diverse health and care needs of patients and supported patients with planning for the future.

Leaders were knowledgeable about issues and priorities for the services they managed.

However, the service did not consistently ensure that some medicines were stored, recorded, and administered correctly. Managers took immediate action to address each issue, and there was no impact on the safety of patient treatment.

Updated 12 June 2025

Baldock Manor is an independent hospital provided by Nouvita Limited delivering acute and psychiatric intensive care services. Baldock Manor is registered to provide the following regulated activities:

Assessment or treatment for persons detained under the Mental Health Act 1983. Treatment of disease, disorder or injury.

Baldock Manor has 4 wards:

Radley and Oakley wards are 8 bed psychiatric intensive care units for women of working age detained under the Mental Health Act. Oakley ward was temporarily closed at the time of our onsite visit due to refurbishment.

Mulberry ward is a 10 bed acute ward for men over the age of 55.

Burberry ward is a 14 bed acute ward for women over the age of 55.

We last inspected the service in July 2024 where it was rated as good overall. However, we found that staff did not always complete observations as prescribed and ligature risk assessments were not accurate. There was evidence of security breaches and medication was not always dispensed in line with policy. This led to breaches for safe care and treatment.

At this inspection we found that the provider had met all of the requirements issued following the previous inspection. During this inspection we looked at all quality statements across all key questions, and we rated the service as good.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service admitted patients under the Mental Health Act 1983. Staff had received face to face training on the Mental Health Act which 78% had completed. This was in addition to an e-learning course on mental health awareness covering the Mental Health Act which 96% of staff had completed.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff received assistance from the Mental Health Act administrator based at the hospital.

The provider had relevant policies and procedures that reflected the most recent guidance and staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy. The service's advocate regularly attended the wards. Patients spoke about the support they received from advocacy services. Patients could access independent mental health act advocates if needed.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Records we reviewed demonstrated this.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a Second Opinion Appointed Doctor when necessary.

Staff stored copies of patients' detention papers and associated records correctly and so that they were available to all staff that needed access to them.

The service displayed a notice to tell informal patients that they could leave the ward freely. We saw signs throughout the wards showing this.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. The provider regularly completed audits on the Mental Health Act paperwork to ensure the correct and relevant paperwork was easily accessible and stored correctly.

Mental Capacity Act

Seventy one percent of staff had had face to face training in the Mental Capacity Act. This was in addition to an e-learning course on mental health awareness covering the mental capacity act which 96% of staff had completed.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw evidence of this in patient records.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person's wishes, feelings, culture and history. We saw evidence of this in patient records.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.