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
a
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:
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Ensure there is a robust governance structure in place to improve patient safety, learn from patients’ experience, and improve clinical effectiveness.
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Ensure appropriate management of medicines including controlled drugs and administration of travel vaccinations
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Ensure that appropriated recruitment checks are completed for all staff including appropriate checks through the Disclosure and Barring Service (DBS).
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Ensure there is a radiation protection supervisor (RPS) which is a requirement of Regulation 17 of the Ionising Radiations Regulation 1999 (IRR99).
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Ensure ionizing radiation is mea
sured and monitoring instruments are fit for purpose.
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Ensure medical records for all patients are maintained within the hospital.
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Ensure staff receives appropriate level of safeguarding training as required by current guidance.
We also said the provider SHOULD:
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Ensure that policies are reviewed regularly and version control system is implemented.
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Ensure that clinical waste is managed safely.
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Ensure the environment, including the radiators, is assessed to prevent risk of harm to children.
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Ensure that GP’s undertake mandatory training and that record of staff training is maintained.
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Ensure all staff, including medical staff working under practicing privileges, are appraised and record of it is maintained.
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Ensure there is an effective system to communicate with NHS GP’s about the management of patients with long term conditions.
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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.
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Endeavour to improve the patient satisfaction survey response rate.
Professor Edward Baker
Deputy Chief Inspector of Hospitals