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The Belvedere Private Hospital Requires improvement

We are carrying out a review of quality at The Belvedere Private Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.
All reports

Inspection report

Date of Inspection: 7 November 2012
Date of Publication: 24 February 2012
Inspection Report published 24 February 2012 PDF | 94.86 KB

People should be cared for in safe and accessible surroundings that support their health and welfare (outcome 10)

Not met this standard

We checked that people who use this service

  • Are in safe, accessible surroundings that promote their wellbeing.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 7 November 2012, checked how people were cared for at each stage of their treatment and care and talked with staff.

Our judgement

People who use the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

Reasons for our judgement

The provider had not taken steps to provide care in an environment that was suitably designed and adequately maintained. The provider had a fire policy in place which stated that adequate means of escape in case of fire was provided in each patient area and staff workplace, and that doors to control smoke would be kept closed during a fire alarm. The policy available was dated 2004 and the manager told us this was due for renewal. On 06 September 2012 a fire inspection by a fire officer took place at the hospital and an action plan was produced by the fire officer. The report stated that “most of the doors in the hospital are not fire doors” and that it was recommended by the fire officer that the doors were changed to comply with fire regulations. The inspection report also noted that there needed for a fire evacuation sheet or chair to be in place and a risk assessment completed for all patients staying overnight at the service. On our inspection of 07 November 2012 the manager confirmed that no action had been taken in relation to this fire inspection report. A member of staff told us that there was no equipment available in order to evacuate people from the upstairs rooms in event of a fire and that staff would need to use bed sheets to do so. This lack of action taken following the fire inspection placed patients and staff at risk in the event of a fire.

There was a medical gas pipeline system installed. This was suitable for the size of the premises. The medical gas cylinders were all in date and stored in secure facilities, but the cylinders were not handled in accordance with Health Technical Memorandum 02-01 which presented a risk of harm to staff. The provider was aware of this memorandum and was in the process of making the required arrangements to ensure that the cylinders were handled safely.