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Inspection Summary

Overall summary & rating

Updated 31 July 2018

The Belvedere Private Hospital is operated by Pemberdeen Laser and Cosmetic Surgery Clinic Ltd. The hospital provides cosmetic surgery, mainly breast augmentation, but also abdominoplasty, blepharoplasty and liposuction. We inspected surgery services only.

We inspected this service as a follow up to review the action plan developed following our previous inspection in November 2016. We carried out the unannounced inspection on 27 April 2018.

The key questions we asked during this focused unannounced inspection were, was it ‘Safe, Effective and Responsive' in surgery?

The hospital has had a registered manager in post since 20 May 2015.

We did not rate this service during the previous inspection. This inspection took please to review concerns identified during the previous inspection in November 2016 and review actions taken by the service.

We found the following areas of good practice:

  • Incidents were being reviewed by the medical advisory committee and agreed learning was being decimated.

  • Data was being collected on surgical site infections and they were being reviewed when required.

  • Post-operative follow up appointment patient notes were now being completed.

  • Training had been completed for safeguarding children level 3, immediate life support and cultural needs.

  • Emergency medicines were being audited and expiry dates were being checked.

  • Pregnancy status for all women between 18 and 55 years old was being checked at pre-operative assessments.

  • Patient’s pain scores were being documented and analgesia given if required.

  • Learning from complaints was now a standing item on the agenda of the medical advisory committee.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Inspection areas


Updated 31 July 2018


Updated 31 July 2018


Updated 31 July 2018


Updated 31 July 2018


Updated 31 July 2018

Checks on specific services


Updated 23 February 2016

The provider’s reliance on the registered manager for all aspects of management was a risk to people using the service and to staff. The current manager had introduced improvements since her appointment in January 2015, but she did not have time to undertake all the tasks necessary to ensure the service was safe and reliable.

The manger had identified some risks, but there was no risk register to record and manage identified risks.  Financial information was not integrated with information about risk to support decision-making.

The provider continued to breach regulations relating to infection prevention and control.

The manager was highly visible and accessible, and staff commented positively on her leadership role and the changes she had implemented. However, the high turnover of managers and the absence of processes to ensure continuity contributed to the difficulties of managing the service. The manager did not have access to data from 2014, such as incidents and complaints.

Governance arrangements were unclear, and processes were not in place to ensure clinical standards were met. Many policies were out of date, and in some cases not relevant to this provider.

Staffing levels at the time of this inspection were adequate for the type of surgery undertaken at the service. Procedures were sometimes cancelled, however, when there were not enough staff to meet these levels. The provider had a poor standing with a number of contractors, which affected access to staffing when replacements were required at short notice.

Staff had received mandatory training, but domestic and administrative staff were undertaking tasks without evidence of competence.

The risks of surgery were reduced because the theatre team followed checks and processes to promote safe practice in theatre. Staff assessed patients appropriately post-operatively and met patients’ pain, nutritional and hydration needs.

Patient satisfaction questionnaires indicated a high percentage of patients considered the care and support they received was good. However, surgeons’ consultations with patients about cosmetic surgery did not always meet the recommended standards. Procedures were sometimes cancelled with little notice to the patients.

CQC has issued formal warnings to The Pemberdeen Laser Cosmetic Surgery Clinic Limited telling them that they must make improvements at the Belvedere Private Hospital in the following areas by 4 November 2015:

Regulation 12: Safe care and treatment. The service was failing to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.

Regulation 17: Good governance. The service was failing to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A).