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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.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 September 2019

Belvedere Private Hospital is operated by Pemberdeen Laser and Cosmetic Surgery Clinic Ltd.

The hospital has eight in-patient beds, and the facilities include one operating theatre, anaesthetic room and a recovery room. There are three consultation rooms.

The Belvedere Private Hospital provides cosmetic surgery, mainly breast augmentation, but also abdominoplasty, blepharoplasty and liposuction. We inspected surgery services only using our comprehensive inspection methodology. We carried out an unannounced inspection on 11 June 2019, which we followed up with a further unannounced inspection on 2 July 2019.

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.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was cosmetic surgery including breast augmentation.

Services we rate

This was the first time we have rated this service. We rated it as Requires improvement overall.

  • Staff understood how to identify patients who may be being abused. Staff had training on how to recognise and report abuse, and they knew when it applied. However, staff did not recognise or report situations where individuals may have been at risk of self-harm. There was no clear process for reporting suspected abuse or avoidable harm.

  • The service had suitable premises. However, it was unclear due to the way the service stored their equipment whether the equipment was in use or out of action.

  • The service did not manage patient safety incidents well. Staff did not always recognise and report incidents and near misses. There was no evidence the manager had fully investigated incidents and of learning from the process having been shared with the whole team. There was no evidence that the manager ensured that actions from patient safety alerts were implemented and monitored.

  • The service could not demonstrate it provided care and treatment based on national guidance and evidence-based practice. There was no evidence managers checked to make sure staff followed professional guidance or its own policies and procedures.

  • It was easy for people to give feedback and raise concerns about care received. However, the service could not demonstrate they treated concerns and complaints seriously or investigated them sufficiently and shared lessons learned with all staff.

  • Leaders of the service did not have the necessary skills and knowledge to run a service providing high-quality sustainable care. They did not understand what was required to manage the priorities and issues the service faced.

  • The service did not have a documented vision, strategy or values; however, the owner of the service had a vision for development of the service.

  • Opportunities for career development were not provided by the service. The service provided the opportunity for patients, their families and staff to raise concerns without fear, however there was no robust system to investigate those concerns.

  • The service did not have a systematic approach to improving service quality and safeguarding high standards of care. There was a lack of overarching governance.

  • There were no effective systems in place for managing risks, and there was no evidence risks and their mitigating actions were discussed with the team.

However, we found areas of good practice:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.

  • The service controlled infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

  • When things went wrong, staff apologised and gave patients honest information and suitable support.

  • Staff completed and updated risk assessments for each patient. They kept clear records of assessments.

  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff gave patients enough food and drink to meet their needs.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

  • Staff felt supported and valued.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with one warning notice that affected the service. Details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South East)

Inspection areas

Safe

Requires improvement

Updated 27 September 2019

We have not previously rated this service. At this inspection we rated it as Requires improvement because:

  • Staff understood how to identify patients who may being abused. Staff had training on how to recognise and report abuse, and they knew when it applied. However, there was no clear process for reporting suspected abuse.

  • The service did not manage patient safety incidents well. Incidents and near misses were not recognised and reported by staff, which meant the manager was not always aware of incidents and did not always have the opportunity to investigate them.

  • There was limited evidence to demonstrate that the manager had fully investigated incidents and that lessons learned from the outcome of the investigation was shared with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • There was no evidence that managers ensured that actions from patient safety alerts were implemented and monitored.

  • The service mostly used systems and processes to safely prescribe, administer, record medicines, however, expiry dates of medicines were not always monitored.

Effective

Requires improvement

Updated 27 September 2019

We have not previously rated this service. At this inspection we rated it as Requires improvement because:

  • The service could not demonstrate it provided care and treatment based on national guidance and evidence-based practice.

  • There was no evidence of auditing or other procedures to check that staff followed professional practice standards, guidance or the services own policies and procedures.

  • There was no monitoring of patient’s outcomes by speciality or surgery type.

However,

  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.

  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Caring

Good

Updated 27 September 2019

We have not previously rated this service. At this inspection we rated it as Good because:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

  • Staff provided emotional support to patients, families and carers to minimise their distress.

  • Staff supported and involved patients, families and carers to understand their surgery and make informed decisions about their care and treatment.

Responsive

Requires improvement

Updated 27 September 2019

We have not previously rated this service. At this inspection we rated it as Requires improvement because:

  • It was easy for people to give feedback and raise concerns about care received. However, the service could not demonstrate they treated concerns and complaints seriously or investigated them sufficiently. Lessons learned from complaints were not shared with all staff.

However,

  • The service planned and provided care in a way that met the needs of their patients and the communities it served.

Well-led

Inadequate

Updated 27 September 2019

We have not previously rated this service. At this inspection we rated it as Inadequate because:

  • Leaders of the service did not have the necessary skills and knowledge to run a service providing high-quality sustainable care. They did not understand what was required to manage the priorities and issues the service faced or which were required to meet their regulatory responsibilities.

  • The service did not have a documented vision, strategy or values; however, the owner of the service had a vision for development of the service.

  • Opportunities for career development were not provided by the service.

  • The service provided the opportunity for patients, their families and staff could raise concerns without fear, however there was not a robust system of investigation of those concerns.

  • There were no effective systems in place for managing risks, and there was no evidence risks and their mitigating actions were discussed with the team.

  • The service did not collect, analyse, manage, and use information well to support all its activities.

However

  • Staff felt supported and valued.

Checks on specific services

Surgery

Requires improvement

Updated 27 September 2019

Surgery was the main activity of the hospital. The service was rated requires improvement because there were areas that needed to improve, including understanding safeguarding, reporting and investigating incidents, complaints handling, updating policies and procedures and governance for the service.