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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

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met this standard

We checked that people who use this service

  • Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
  • Other records required to be kept to protect their safety and well being are maintained and held securely where required.

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 were not always protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Reasons for our judgement

At our inspection on 13 September 2012 we found records were not always kept securely. We found an operating list for the day of our inspection which contained personal details about people in a public area. We also found that the treatment files of people using the service were left in an open office and not stored securely. The provider wrote to us and told us they had purchased a lockable records cabinet and that records were stored securely.

At our inspection of the service on 07 November 2012 we found people’s treatment files were not stored securely. A file was open on the desk of an unattended office with an open door and other files were placed in the records cabinet which was not locked.

The service had not complied with the data protection act 1998 and Criminal Records Bureau (CRB) checks were retained in staff files instead of being disposed of appropriately once the provider was satisfied with the content of the CRB check.

Records were not accurate and fit for purpose. For example the front sheet of a person’s inpatient prescription chart had not been completed with details of their drug allergy. The person’s drug allergy was recorded in another part of their file, and the information was missing from the prescription chart and therefore not available immediately to staff prescribing or administering medication. This increased the risk of a person receiving unsuitable medication.

Staff records and other records relevant to the management of the services were not all accurate and fit for purpose. The signing in and out records did not accurately represent the movements of staff during a shift. For example a staff member informed us they had left the hospital for a period of around two to three hours on the afternoon of the 06 November 2012. However this absence was not recorded on the hospital’s system for signing in and out. Another staff member had signed in at 19.30 on the 06 November 2012 but there was no record of their signing out the next day although we were told they had worked a night shift and had left the hospital on the morning of the 07 November 2012.

The manager confirmed that they had given staff training on the signing in and out system but it was not clear if the training had included information about the length of absence for which the system should be used. The manager confirmed there was no policy in place which informed staff when to use the system. This meant that there was a risk that staff could not be held accountable for any issues regarding a person’s care and also that there was no accurate record of the number of people in the building in the event of fire.