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Inglewood Private Hospital

725 Inglewood Avenue, West Vancouver BC V7T 1X5 · Private Hospital

Official record from Vancouver Coastal →

Inspection summary

Inglewood Private Hospital has been inspected 7 times by Vancouver Coastal Health since October 7, 2021. The most recent inspection, on June 17, 2024, found no infractions.

1 of 7 inspections on record found no infractions at all. No inspections are on record from the past 12 months. All recorded findings relate to upkeep, equipment or paperwork rather than direct health risks.

Recent inspections have recorded fewer infractions than earlier ones, so the record is improving.

What these findings mean

Health authorities word their findings differently, so we group them by what they mean for the people in care. Higher-risk findings are the ones that could directly make someone sick, and they matter more here because young children, older adults and people who are unwell are more vulnerable to infection.

  • Permits, records and postingLower risk

    Operating permits, required signage, written procedures and logs. These findings are administrative: the documentation was missing or out of date at the time of inspection.

    Recorded 18 times across 4 separate inspections, most recently on October 6, 2022. For example: Persons in care who make prepayments are provided written terms and conditions under which a refund may be made [CCALA Sec 19; Bill of Rights 4(d)]

  • Food safety training and certificationLower risk

    Many jurisdictions require a trained or certified person on site, such as a certified food handler. These findings mean the training record or the trained person was missing at the time. They do not by themselves mean anything was handled unsafely.

    Recorded 6 times across 4 separate inspections, most recently on October 6, 2022. For example: If a person in care is restrained, the information required by the regulation is recorded in the care plan of the person in care [RCR Sec 84]

  • Equipment and utensilsLower risk

    Equipment has to be made of cleanable materials, kept in good repair and stored properly. These findings are mostly about upkeep, like a cracked surface or worn part. They are generally lower risk but show how well the place is maintained.

    Recorded 5 times across 4 separate inspections, most recently on October 6, 2022. For example: Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]

  • Building, plumbing and upkeepLower risk

    Floors, walls and ceilings must be clean and in good repair, with working lighting, ventilation, plumbing, hot and cold water, and washrooms. These are rarely an immediate health risk on their own, but persistent problems can lead to pest or sanitation issues.

    Recorded once on July 12, 2022. For example: The facility provides comfortably furnished lounge facilities and at least 1.5 m2 of usable floor space in total for each person in care[RCR Sec 34(2)(a)][Transitioned]

  • Other findingsLower risk

    Findings that do not fit the categories above, such as follow-ups that confirm an earlier violation was corrected, or requirements specific to this type of facility.

    Recorded 17 times across 6 separate inspections, most recently on October 5, 2023. For example: A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]

About this data

These results come from Vancouver Coastal Health, which inspects food premises and other public facilities in this area. We republish the authority's public disclosure data and refresh it regularly; the official record is the final word.

7 inspections

  1. Routine

    0 infractions

  2. Routine

    1 infraction

    • A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]
      • There is no written agreement to the use of a restraint by the person in care or their representative.
  3. Routine

    1 infraction

    • A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]
      • There was no agreement in writing from the person in care or their representative.
      • There was no agreement in writing from the medical practitioner or nurse practitioner
  4. Routine

    8 infractions

    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
    • Persons in care who make prepayments are provided written terms and conditions under which a refund may be made [CCALA Sec 19; Bill of Rights 4(d)]
    • A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]
      • A restraint was used when it was not necessary to protect the person in care or others from imminent serious physical harm.
      • There is no written agreement to the use of a restraint by the person in care or their representative.
    • Restraints are not used unless it is necessary to protect the person in care or others from serious physical harm, are minimal as possible; safety, physical, emotional dignity is monitored and the regulation is followed [RCR Sec 73(1),(2)]
      • All alternatives to the use of the restraint have not been considered and either implemented or rejected.
      • The use of the restraint, its type and the duration for which it is used is not documented in the care plan of the person in care.
    • Care plans take into account the persons in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences [RCR Sec 81(2)(b); Bill of Rights 1(b)]
    • If a person in care is restrained, the information required by the regulation is recorded in the care plan of the person in care [RCR Sec 84]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
    • Ongoing tray service is reassessed every 30 days by the person in care's medical practitioner, nurse practitioner or dietician[RCR Sec 63(3)(c)(iv)]
  5. Routine

    18 infractions

    • Employees on duty are sufficient in numbers, training, experience, and organized in an appropriate pattern to meet the needs of the persons in care and assist in activities of daily living. [RCR Sec 42(1);DOLSOP Opioid Overdose Prevention]
      • The employees lack training and experience to assist with eating in a manner consistent with the health safety and dignity of persons in care.
      • There are insufficient numbers of employees.
      • The employees lack training and experience to assist in activities of daily living in a manner consistent with the health safety and dignity of persons in care.
    • There are employees who can communicate effectively at all times with all the persons in care [RCR Sec 42(3)]
    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
    • There is an emergency plan displayed in a prominent place that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for evacuation and how persons in care will be cared for [RCR Sec 51(1),(4)]
      • Emergency plan does not include all required elements.
      • The emergency plan does not include procedures for evacuation.
      • There is no plan for how persons in care will continue to be cared for in an emergency.
    • There is access to a fair, prompt and effective process to express concerns, make complaints or resolve disputes within the facility [RCR Sec 60; Bill of Rights 3(d)]
      • There is no process to express concerns, make complaints or resolve disputes.
      • Complaints, concerns and disputes are not responded to promptly.
    • Care plans take into account the persons in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences [RCR Sec 81(2)(b); Bill of Rights 1(b)]
      • Did not use CAPs to inform care planning.
    • Reportable incidents have been reported to the Medical Health Officer in the form and manner required. [RCR Sec 77(2)(c)]
    • Reportable incidents have been reported with appropriate notifications [RCR Sec 77(2)(a)(b)(d);DOLSOP Preventing Opioid Overdose]
    • The facility is operated in a manner that promotes the health, safety and dignity of persons in care, and their rights [CCALA Sec 7(1)(b)(i); Bill of Rights 2(a)]
    • The facility operates in a manner that promotes in the case of adult persons in care, the rights of those persons in care [CCALA Sec 7(b)(ii)]
    • Sufficient materials, supplies and equipment for the program of activities are readily accessible and safe, and provided without charge [RCR Sec 55(3); Bill of Rights 2(c)]
      • Supplies, materials and equipment are not readily accessible and safe.
    • Ongoing tray service is reassessed every 30 days by the person in care's medical practitioner, nurse practitioner or dietician[RCR Sec 63(3)(c)(iv)]
    • Monthly weights are taken and recorded, if missing, the reason is documented. [RCR Sec 83(4)(a),(5)(a)]
    • There is a MSAC with the appropriate membership [RCR Sec 68(1)]
    • Nutrition supplements or tube feedings are provided as required by the nutrition plan or as ordered is provided [RCR Sec 67(1)(a)(b)]
      • Nutrition supplements are not provided as ordered.
    • The facility provides comfortably furnished lounge facilities and at least 1.5 m2 of usable floor space in total for each person in care[RCR Sec 34(2)(a)][Transitioned]
    • Employee files contain the records required by this regulation [RCR Sec 86]
      • Lacks a record of compliance with the Province's immunization and tuberculosis control programs.
      • Lacks a record of character references.
      • Does not contain criminal record check results.
    • A record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them is kept [RCR Sec 89(1)]
  6. Routine

    10 infractions

    • Employees have access to reliable communications equipment in an emergency [RCR Sec 51(5)]
    • Employees on duty are sufficient in numbers, training, experience, and organized in an appropriate pattern to meet the needs of the persons in care and assist in activities of daily living. [RCR Sec 42(1);DOLSOP Opioid Overdose Prevention]
    • A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]
    • There are written and implemented policies and procedures to guide staff in the care and supervision of the persons in care [RCR Sec 85(1)(a), (d)]
    • Restraints are not used unless it is necessary to protect the person in care or others from serious physical harm, are minimal as possible; safety, physical, emotional dignity is monitored and the regulation is followed [RCR Sec 73(1),(2)]
    • Care plans take into account the persons in care's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences [RCR Sec 81(2)(b); Bill of Rights 1(b)]
    • The implementation of care plans is monitored on a regular basis to ensure proper implementation [RCR Sec 81(4)(a)]
    • Reportable incidents have been reported to the Medical Health Officer in the form and manner required. [RCR Sec 77(2)(c)]
    • If a person in care is restrained, the information required by the regulation is recorded in the care plan of the person in care [RCR Sec 84]
    • The most recent routine inspection record is displayed in a prominent place. [RCR Sec. 11(1) (b), (2); Bill of Rights 4(b)]
  7. Routine

    9 infractions

    • Employees on duty are sufficient in numbers, training, experience, and organized in an appropriate pattern to meet the needs of the persons in care and assist in activities of daily living. [RCR Sec 42(1);DOLSOP Opioid Overdose Prevention]
      • There are insufficient numbers of employees.
    • Employees have been trained in the implementation of the plans and in the use of emergency equipment [RCR Sec 51(3)]
      • Employees have not been trained in the emergency plan.
    • Prior to and or on admission persons in care are informed on how to express concerns or make complaints to the medical health officer or the Patient Care Quality Office [RCR Sec 48(1) (c); Bill of Rights 3(e)]
      • Persons in care are not advised on how to express concerns or make complaints to the medical health officer.
      • Persons in care are not advised on how to express concerns or make complaints under the Patient Care Quality Review Board Act.
    • A restraint may be used if the restraint is necessary to protect the person in care or others from imminent serious physical harm, or there is agreement as per the regulation [RCR Sec 74 (1)]
      • A restraint was used when it was not necessary to protect the person in care or others from imminent serious physical harm.
      • There was no agreement in writing from the person in care or their representative.
      • There was no agreement in writing from the medical practitioner or nurse practitioner
    • There are written and implemented policies and procedures to guide staff in the care and supervision of the persons in care [RCR Sec 85(1)(a), (d)]
      • Policies and procedures are not implemented by staff.
    • Restraints are not used unless it is necessary to protect the person in care or others from serious physical harm, are minimal as possible; safety, physical, emotional dignity is monitored and the regulation is followed [RCR Sec 73(1),(2)]
      • Employees administering the restraint have not received training in alternatives to the use of restraints and determining when alternatives are most appropriate, and the use and monitoring of restraints.
      • All alternatives to the use of the restraint have not been considered and either implemented or rejected.
      • The use of the restraint, its type and the duration for which it is used is not documented in the care plan of the person in care.
      • The safety, physical and emotional dignity of the person in care is not monitored throughout the use of the restraint, and assessed after the use of the restraint.
    • The care plan(s) contains all items that must be recorded under this regulation [RCR Sec 81(3)]
      • Does not address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
      • Does not include a fall prevention plan.
    • If a person in care is restrained, the information required by the regulation is recorded in the care plan of the person in care [RCR Sec 84]
      • The reason for the use of the restraint is not recorded.
      • The result of any reassessment of the use of the restraint is not recorded.
      • The alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected is not recorded.
      • The type or nature of the restraint used is not recorded.
      • Employee compliance with the requirements of Division 5 [Use of Restraints] of Part 5 is not recorded.
      • The duration of the restraint and the monitoring of the person in care during the restraint are not recorded.
    • Screening is done prior to admission to ensure safe and adequate care [RCR Sec 47(1), (2)]

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