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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.
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Inspection report

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

There should be enough members of staff to keep people safe and meet their health and welfare needs (outcome 13)

Not met this standard

We checked that people who use this service

  • Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

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

There were not enough qualified, skilled and experienced staff to meet people’s needs.

Reasons for our judgement

There were not enough qualified, skilled and experienced staff to meet people’s needs. A person had required an overnight admission at the hospital following their surgery. We were told by staff that it was normal practice that a Responsible Medical Officer (RMO) would remain on site at all times when a person was admitted to the hospital. This was confirmed in a document provided by staff which stated the roles and responsibilities of the RMO and included providing “a twenty four hour medical service within the hospital or as long as patient’s remain on hospital”. On the day of our inspection staff told us that there had been no RMO cover over night on 06 November 2012 to support the care needs and monitoring of two people who had required an overnight stay following there surgery. Staff said that the RMO that had been booked via the agency but had not arrived and this had been reported to senior management but no alternative cover had been found. On the day of our inspection there was also no RMO on duty until 12:00 and therefore no adequate medical cover for patients recovering from surgical procedures within the ward areas.

On the 06 November 2012 only one qualified nurse was documented as working a long day on the rota for the ward. This nurse told us they were absent from the hospital for two to three hours and also used some time to rest during the shift in preparation for a night shift. This nurse was the only staff member recorded on the ward rota as being on duty at that time. We were told by the manager that there had been sufficient numbers of staff on duty on the 06 November 2012 to cover any meal breaks or absences from the ward but they could not present us with evidence to demonstrate this was the case.

The manager told us that they did not organise or take responsibility for the ward or theatre duty rota, and that staff were able to identify their own working patterns in line with the needs of the hospital. However there was no policy or risk assessment in place regarding the reliability of this method of allocating shifts. The manager also had to guess at what the term ‘LD’ stood for on the rota, which meant a staff member worked 8 am until 8pm. This meant that the manager was not able to adequately monitor the number of appropriately skilled and experienced staff on duty at any given time, and therefore identify and correct any skills shortage.

We saw from the duty rota that a member of staff was allocated to cover two duty shifts from 08.00 on 06 November 2012 until 08.00 on 07 November 2012. This indicated that a twenty four hour period was being covered by one member of staff and we confirmed at inspection that this staff member in fact worked until 15.40 on 07 November 2012. This meant that the staff member had been on duty for 31 hours and 40 minutes, and for fourteen hours was the most senior person on duty. The manager confirmed that a member of staff working these hours would be overworked.