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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.

Reports


Inspection carried out on 11 June, 2 and 26 July 2019

During a routine inspection

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 carried out on 27 April 2018

During an inspection to make sure that the improvements required had been made

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 carried out on 1 November 2016

During a routine inspection

Belvedere Private Hospital is operated by Pemberdene 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 is one consultation room with two new consulting rooms being built at present.

The Belvedere Private Hospital provides cosmetic surgery, mainly breast augmentation, but also abdominoplasty, blepharoplasty and liposuction. We inspected surgery services only.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 1 November 2016, along with an unannounced visit to the hospital on 9 November 2016.

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.

We do not currently have a legal duty to rate cosmetic surgery services or the regulated activities they provide but we highlight good practice and issues that service providers need to improve.

We found the following issues that the service provider needs to improve:

  • Incidents were not discussed at the medical advisory committee or governance meetings. Further, consultants were required to attend at least two medical advisory committee and governance meetings per year as per hospital policy; we did not see evidence of adherence to this policy.

  • The processes to monitor risks to patients and staff were not fully implemented. A patient with history of depression had not undergone psychological assessment as per the hospital’s guidance. Female patients did not routinely receive a pregnancy test on the morning of their surgery. Further, during the post-operative recovery period patients were not assessed and monitored in accordance with a suitable assessment tool.

  • With regard to infection prevention and control, a bed pan was stored in a patient bathroom on the floor. There was out of date antibacterial skin cleanser in a patient bedroom.

  • Equipment did not always show evidence of having been subjected to safety checks. there were two pieces of electrical equipment in theatre for which safety testing had expired in April 2016, fire extinguishers in the ward area were not secured in line with Regulation Reform (Fire Safety) order 2005.

  • There were no window restrictors on the windows in patient’s rooms on the 1st floor.

  • The safeguarding children’s policy did not reflect the most up to date guidance. Further, the level of safeguarding training required of staff was not stated.

  • No member of employed staff had undertaken immediate life support (ILS) training.

  • The registered manager did not have access to clinical supervision or peer review.

  • Learning from complaints was not clearly demonstrated.

However, we found the following areas of good practice:

  • The patient guides on specific surgeries, provided a great deal of useful information for patients about what to expect before, during and after their surgical procedures.

  • The theatre and ward areas were visibly clean.

  • All patient records we reviewed demonstrated communication with the patient’s GP by means of a standard letter pre and post-operatively

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. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 25 February 2016

During an inspection to make sure that the improvements required had been made

The Belvedere Private Hospital provides cosmetic surgery to private patients. After we carried out a comprehensive inspection of The Belvedere Private Hospital on 4 and 5 August 2015, CQC issued formal warnings that they must make improvements by 4 November 2015 in the following areas.

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

  • The infection control processes were not in line with best practice.
  • The domestic assistant had not received training on safe waste management or in the specific requirements for infection prevention and control in theatres.
  • There was no back up anaesthetic machine.
  • The fenced off area containing ventilation system and medical gases was left unlocked.
  • Taps were not run on a regular basis, in line with the clinic’s legionella policy.

Regulation 17: Good governance. The provider did not have systems and processes that ensured they were able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A).

  • There was no risk register in place.
  • External assessments had identified risks, but there was no action plan to address these risks.
  • Records were missing for parts of 2014 so the provider was unable to tell us about incidents, complaints or cancellations during that time.
  • The incident reporting policy was not up to date.

The registered manager sent us a plan telling us what action the provider was taking to make the necessary improvements. We returned for an unannounced inspection on the 25 February to find out if the provider had made these improvements.

Our key findings from the February 2016 inspection were as follows:

The registered manager and provider had taken the following action in response to the warning notices:

  • Commissioned external companies to update policies and improve processes for health & safety, and infection control.
  • Arranged training for domestic assistants.

  • Purchased a backup anaesthetic machine.
  • Set up a risk register, which recorded some risks and what had been done to address these.
  • Recorded action taken to address risks from an external fire risk assessment.

There were still some areas of poor practice where the provider needed to make improvements.

  • Processes to monitor the activity of the service and the risks to patients and staff were in place, but had not been fully implemented.
  • The Adverse Incident Policy did not include recent regulatory requirements.
  • The consulting room was carpeted and had not been cleaned as scheduled. The sharps bin in the room had not been replaced when required.

Importantly, the provider must ensure:

  • The risk register is developed to record all existing and potential risks, and to identify action to address and mitigate the risks.
  • The registered manager has appropriate support to carry out their duties.
  • The duty of candour is included in the adverse incident policy.

In addition, the provider should ensure:

  • Incidents or near misses are discussed at meetings of the Medical Advisory Committee and shared with staff.
  • The flooring in the consulting rooms is compliant with infection protection and control guidance.
  • Sharps bins are disposed of when they become an infection control risk.

CQC has issued a requirement notice to The Pemberdeen Laser Cosmetic Surgery Clinic Limited telling them to make further improvements.

We have not published a rating for this service.CQC does not currently have a legal duty to award ratings for those hospitals that provide solely or mainly cosmetic surgery services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4 & 5 August 2015

During a routine inspection

The Belvedere Private Hospital provides cosmetic surgery to private patients. The Pemberdeen Laser Cosmetic Surgery Clinic Limited owns and manages the service.

The service carries out about 400 cosmetic procedures a year, predominantly breast augmentation. Most procedures are day cases, with a small number of overnight admissions. There are no critical care facilities available at the service.

Services are available to people paying for one-off treatment.

We carried out a comprehensive inspection of The Belvedere Private Hospital on 4 and 5 August 2015. The inspection formed part of a pilot programme of inspections in independent healthcare settings. The inspection reviewed surgical services as this is the one core service provided by the service from the eight that that are usually inspected by the Care Quality Commission (CQC) as part of its approach to hospital inspection.

We have not published a rating for this service. CQC does not currently have a legal duty to award ratings for those hospitals that provide solely or mainly cosmetic surgery services.

We identified the service for inspection based on a history of non-compliance with regulations.

Overall we found the quality of care was unsatisfactory and needed urgent improvement. Our key findings are as follows:

Are services safe at this hospital/service

• There were continuing breaches of regulations with regard to infection prevention and control. We found clinical waste from the previous day in the ward bins after patients had been admitted to the ward. There was no action plan to remedy issues found in an external audit in June 2015. The domestic assistant cleaned the theatre regularly and disposed of clinical waste, but had not received training in the specific requirements for infection control and prevention in theatres or in waste disposal.

• The provider had commissioned external companies to carry out a fire risk assessment and a health and safety risk assessment. However, there was no formal plan to address the issues identified in these assessments and audits.

• The systems for the investigation of incidents and dissemination of learning from incidents were insufficiently robust and failed to ensure that the risk of recurrence was minimised. The incident policy had not been updated to incorporate the duty of candour.

• There was no backup anaesthetic machine and no plans to purchase one at the time of our inspection. One of the resuscitation trolleys jammed and would not fully open during our inspection. The manager immediately ordered a replacement. There were regular checks on theatre and other equipment. The manager had put in place processes ensure there were sufficient instrument sets and consumables to carry out planned procedures.

• The staffing levels were appropriate for the type procedures undertaken, and surgery did not take place without a full theatre team. Staff received mandatory training.

• Medicines were stored safely and there were regular, recorded checks of the temperature of the fridges storing medicines.

• Patient records were sometimes incomplete or contained inaccuracies.

• A nurse assessed all patients before surgery was confirmed.

• Surgical, medical and theatre staff followed the ‘five steps to safer surgery’ to ensure that safety checks were followed.

• Nurses monitored patients post-operatively and referred to the resident medical officers (RMO) on duty if necessary. On the rare occasions when recovery was not straight forward, patients went to the nearest NHS hospital emergency department. However, the RMOs on duty at the time of our inspection did not have advanced life support training: the anaesthetist in theatres was the only person on site with this training. There had been no practice emergency scenarios, and the service did not have a resuscitation lead.

Are services effective at this hospital/service

• The registered manager reviewed guidance, and maintained an overview of practice standards in theatres. There were checks in place to support adherence to these standards.

• The surgeons working at the service took professional responsibility for following national and Royal College of Surgeons guidance.

• There was no clinical audit programme to identify the standards the provider expected to meet or to monitor adherence to these. When there were audits, it was not clear whether these were new audits or re-audits and whether the service was ensuring the implementation of actions arising from them.

• The provider did not collate information about outcomes for patients, and the process for identifying areas for improvements relied on surgeons each reviewing outcomes and discussing these informally. When the Medical Advisory Committee (MAC) made decisions about changing practice, these were not always disseminated to surgeons.

• The MAC was responsible for granting and overseeing practicing privileges for the surgeons who carried out procedures. We were not assured that surgeons working privately were adhering to the General Medical Council (GMC) revalidation process.

• The manager and deputy manager had received appraisals and some training was identified as a result. There was a lack of clinical supervision or peer support for the manager. The manager checked that agency, bank and locum staff had appropriate qualification before engaging them. There was no assurance that domestic and administrative staff had the competencies required to undertake their allocated tasks.

• Surgeon's consultations with patients were sometimes brief, without evidence of discussions about risks or the expectations of the patient. Administrative staff provided further information to patients. None of the administrative or nursing staff had training in the Mental Capacity Act 2005 or were able to explain how the Act might be relevant to people seeking cosmetic surgery. There was always a waiting period, with time for the patient to reflect between their consultation with the surgeon and the signing of consent for the procedure.

• There were processes in place for the management of patients’ pain. Staff supported patients to eat and to drink enough fluids.

Are services caring at this hospital/service

• Patients we spoke with during the inspection confirmed that staff were kind, considerate and respectful.

• We observed interactions between the staff, consultants and patients and saw that staff were attentive and caring in their attitude, providing assurance and support when needed.

• Prospective patients were given written information about cosmetic surgery, including fees.

Are services responsive at this hospital/service

• The facilities and premises were appropriate for the services provided.

• The provider planned its services around patient demand. At the time of this inspection surgery was carried out over two (occasionally three) days every fortnight.

• Patients sometimes experienced delays because of the limited opening hours of the service, and procedures were sometimes at cancelled at late notice. There had been 27 operations cancelled over the past year.

• The written information given to patients was in English and there was no provision to provide interpreters for patients who did not speak and/or read English.

• The service had a complaints policy and procedure in place and there was information available for patients about how to raise concerns. Twelve complaints made in 2015 had been recorded and responded to. Most of these related to either cancelled operations or poor outcomes.

• Staff gave patients questionnaires so that they could feed back their experience of care. The majority of feedback from patients was positive.

Are services well led at this hospital/service

• The safety and quality of service was reliant on the manager, who was responsible for clinical governance, running the service, and managing risk. There was a history of instability, with a high turnover of managers, and of failure to set up processes and systems to support continuity.

• There was no system in place to identify, record, and address or mitigate risks. There was a disconnection between risk assessment and the identification of the resources to reduce the risk. The manager had identified areas for improvement, but the provider had no strategy to implement these. The provider did not have a credible business plan and there was evidence of poor financial standing with contractors.

• We were unable to establish that appropriate quality measurement systems were in place as relevant documentation was not available.

• Staff commented favourably on the changes made since the current manager took up her post. They felt she was approachable, visible and provided strong leadership. Feedback from patients was positive.

There were areas of poor practice where the provider needed to make improvements.

Importantly, the provider must ensure:

• A risk register is established, which records existing and potential risks, and identities action to address and mitigate the risks.

• There are effective systems to assess, monitor and improve the quality and safety of the services provided.

• There are processes in place to integrate information about risk and identified improvements with financial information in order to support decision-making.

• All incidents are recorded and appropriately investigated and, where required, notified to the Care Quality Commission.

• A programme of complete clinical audit cycles is established to monitor and improve quality of care.

• The medical advisory committee (MAC) reviews information about doctors and surgeons with practicing privileges and ensures they are complying with GMC requirements for registration.

• Lessons learnt from incidents or near misses, and decisions made at the MAC meetings and staff meetings are shared with staff.

• Policies and procedures are up-to-date, relevant to the provider and put into practice at the hospital.

• The registered manager has appropriate support to carry out her duties and to ensure the service operates safely in her absence.

• All staff are appropriately trained for the roles they perform.

• Long-term bank and agency staff receive an annual appraisal and regular supervision.

• Staff participate in simulation exercises so they are aware of the action they need to take in an emergency.

• There are infection prevention and control systems and processes in place.

• The hospital has sufficient equipment for the procedures it performs and for the safety of its patients.

• Appropriate risk assessments are carried out, recorded, reviewed and, where remedial action is identified, this is taken.

• Records are accurate, fit for purpose, and retained for an appropriate duration.

• Training and support is provided so that all relevant staff are familiar with the Mental Capacity Act 2005 and understand how they should apply it in practice.

• There is appropriate security in high-risk areas.

• There is a review the changes to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) (as amended) and, in particular, the duty of candour.

In addition the provider should:

• Provide evidence that surgeon’s consultations with prospective patients meet professional standards.

• Set up a forum for staff to give feedback.

• Review the staffing structure so staff share lead roles rather than all of them sitting with one person.

• Review its website to ensure all information provided is accurate and meets Advertising Standards Authority (ASA) and professional standards.

• Provide access to interpreter services for patients whose first language is not English.

• Establish lines of communication to ensure good practice guidelines and safety alerts are shared with all staff.

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).

Professor Sir Mike Richards

Chief Inspector of Hospitals

During a check to make sure that the improvements required had been made

We inspected the service in order to check that the service was compliant with expected standards. During an inspection at the hospital in April 2014, when we visited the hospital, observed care and looked at records, we found that the provider had addressed our concerns in the way the hospital managed medicines, planned care and treatment, recruited staff and maintained care records. During our recent review of the service, in August 2014, we asked the provider to send us documents so we could check that the provider had addressed concerns in other areas. We did not visit the hospital on this occasion.

We found the provider was meeting the six standards we have reviewed.

Inspection carried out on 28 April 2014

During an inspection to make sure that the improvements required had been made

We inspected the service in order to follow up concerns from previous inspections. At this inspection we found that the provider had addressed our concerns in the way the hospital managed medicines, planned care and treatment, recruited staff and maintained care records.

Inspection carried out on 29 November 2013

During an inspection to make sure that the improvements required had been made

We inspected the service in order to follow up concerns from previous inspections. At this inspection we identified continued concerns in the way the hospital managed medicines, planned care and treatment, recruited staff and maintained care records.

Inspection carried out on 4 September 2013

During an inspection to make sure that the improvements required had been made

We inspected the service in order to follow up concerns from previous inspections. At this inspection we identified continued concerns in the way the hospital managed medicines. The service did not operate effective recruitment procedures and staff were not all trained in topics the provider told us they considered to be mandatory. There was a lack of appropriate infection control systems in place and complaints were not handled appropriately in all cases. The provider did not ensure that there were sufficient numbers of skilled and experienced staff available at all times and records were not accurate and fit for purpose in some cases.

Inspection carried out on 5 June 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection in order to follow up on non-compliance found at our inspections on 11 and 12 March 2013 when we found people who use the service were not given appropriate information and support regarding their care or treatment. At this inspection we found the provider had not taken action to ensure people were provided with appropriate information and support.

Inspection carried out on 11, 12 March 2013

During an inspection in response to concerns

We inspected the hospital on 11 and 12 March 2013 in response to concerning information received about staffing levels at the service and we found there were not always sufficient staff available at the hospital. During our inspections we found the hospital did not treat people with consideration by keeping them clearly informed about timings of surgical procedures. We also found the hospital did not have appropriate measures in place to deal with foreseeable emergencies and did not always take steps to ensure safety and welfare of people using the service. Medicines were not all stored safely and the hospital did not take necessary steps to ensure only suitable staff were employed by the service

Inspection carried out on 13 September 2012

During an inspection to make sure that the improvements required had been made

We were able to speak with one person on the day of our visit. This person found the staff pleasant and the hospital clean.

However, we identified other concerns with the service.

Inspection carried out on 28 May 2012

During a routine inspection

At this inspection, we were not able to speak to people using the service because we inspected on a day when there were no patients admitted or visiting the hospital.

We were able to gather some evidence of people’s experiences of the service by reviewing peoples’ post-operation feedback comments and found that the majority had rated the quality of care and treatment highly, although there was one negative comment made about the lack of information provided.

Inspection carried out on 8 January 2013

During an inspection to make sure that the improvements required had been made

We previously inspected this service on 07 November 2012 in order to check on issues we had identified at earlier inspections. At our inspection of 07 November 2012 we found the provider was not meeting several essential standards. The provider was not storing records securely and they were not kept accurately in all cases. The provider had not carried out checks in all cases to ensure only suitable staff were employed by the service. We wrote to the provider and asked them to address these issues and we returned on 08 January 2013 to check they had done so. At our 08 January 2013 inspection we found the provider remained non-compliant with these issues.

Inspection carried out on 7 November 2012

During an inspection to make sure that the improvements required had been made

We inspected the service on 07 November 2012 in order to check on actions we had asked the provider to take, with regards to the care and welfare of people using the service and the management of medicines for people using the service. We found that the provider continued to be non-compliant with care and welfare and the management of medicines, and we found other concerns to do with the checks made on staff working at the service, the number of suitable staff working at the service and the way records were stored and completed. We also found concerns with infection control, and the safety of the premises. We were not able to speak with anyone using the service on this occasion because the only person admitted to the service at the time of our inspection was recovering from surgery.

Reports under our old system of regulation (including those from before CQC was created)