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The Belvedere Private Hospital Inadequate

Inspection Summary

Overall summary & rating


Updated 26 August 2020

The Belvedere Private Hospital is operated by Pemberdeen Laser Cosmetic Surgery Limited. The hospital has eight beds. Facilities include one operating theatre, and three consulting rooms.

The hospital provides surgery. We inspected surgery as part of a focused follow up inspection following an inspection which took place in June and July 2019, following which we issued the service with a warning notice requiring them to address concerns highlighted.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 29 January 2020.

Following the inspection the service has worked to implement the changes required as identified within this report. This work continues and will be reviewed when the service is next inspected.

Services we rate

Our rating of this service went down. We rated it as Inadequate overall.

We took urgent enforcement action in response to our concerns. The provider was asked to send us evidence demonstrating how they were addressing the areas of concern relating to the following areas:

  • The maintenance and use of facilities, premises and equipment was not sufficient to keep people safe. Staff were trained to use equipment but could not always demonstrate compliance to guidance and procedures for checking equipment was safe to use.
  • Staff completed and updated some risk assessments for patients but could not demonstrate risks were removed or minimised. Some staff could not demonstrate how they would identify and or act upon patients at risk of deterioration.
  • The service could not demonstrate effective systems and processes to safely record and store medicines.
  • The service did not managed patient safety incidents well. There was no evidence managers fully investigated incidents. There was a lack of evidence to show lessons learned were shared with the whole team.
  • The service could not demonstrate it provided all care and treatment based on relevant national guidance and evidence-based practice or that managers checked to make sure staff followed the guidance that was in place.
  • Staff did not always complete in full, detailed records of patients’ care and treatment.
  • The service could still not demonstrate they treated concerns and complaints seriously or investigated them sufficiently or shared lessons learned with all staff.
  • Leaders of the service still 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 strategy to turn the vision and strategic objectives into action. The vision and strategy were focused on sustainability of services. Staff did not understand or know how to apply this in practice or how progress was monitored.
  • The service still did not have a systematic approach to improving service quality and safeguarding high standards of care. There remained a lack of overarching governance.
  • The risk assessment system used by the service was ineffective and there was no evidence the risk assessment system included discussions with the team about risks and mitigating actions.

  • The service could still did not demonstrate it had a systematic approach to learning from when things went wrong and continuously improving.

However, we found areas of improvement:

  • Records when completed were clear, stored securely and easily available to all staff providing care.
  • Staff were now recognising and reporting incidents and near misses.
  • We found it was easy for people to give feedback and raise concerns about care received in the service.
  • The service now had a vision for what it wanted to achieve.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and the South)

Inspection areas



Updated 26 August 2020



Updated 26 August 2020



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.


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.


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



Updated 26 August 2020

Checks on specific services



Updated 26 August 2020

Surgery is the main activity within this hospital. The service was rated as inadequate because there were several areas of concern, which impacted on the safety of people using the service. This included concerns about the operating theatre environment, lack of safety checks on equipment and poor maintenance of some equipment items. Expected risk assessments and safety checking procedures were not always undertaken. Patient records were not always fully completed.

Systems to monitor and respond to incidents and complaints were not fully developed, and the governance of the services was insufficient.