Source · CQC inspection

Birmingham

Type Independent Healthcare Org Region West Midlands Last inspected 13 Nov 2023

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 9 should-do

Should-do actions (9)

Recommended improvements to enhance service quality.

Should-do action 1 of 9
Should do
Safe
The service should ensure infection prevention and control systems provide assurance of safety and meet national best practice standards. Regulation 12.
Regulation: Regulation 12
Should-do action 2 of 9
Should do
Safe
The service should ensure staff manage the risks of domestic electrical equipment. Regulation 15.
Regulation: Regulation 15
Should-do action 3 of 9
Should do
Safe
The service should consider how to better manage clinical waste disposal when both theatres are in use. Regulation 15.
Regulation: Regulation 15
Should-do action 4 of 9
Should do
Safe
The service should ensure air purifiers in surgical theatres are fit for purpose in the areas installed. Regulation 15.
Regulation: Regulation 15
Should-do action 5 of 9
Should do
Responsive
The service should ensure the new complaints manager improves the breadth and depth of learning from complaints. Regulation 16.
Regulation: Regulation 16
Should-do action 6 of 9
Should do
Responsive
The service should ensure the independent adjudication process is clearer and more readily accessible. Regulation 16.
Regulation: Regulation 16
Should-do action 7 of 9
Should do
Responsive
The service should ensure delays and disruption to clinics are consistently managed and communicated to patients. Regulation 17.
Regulation: Regulation 17
Should-do action 8 of 9
Should do
Well-led
The service should ensure improvements to clinical governance, quality assurance, and risk management continue to be developed and are fully embedded in the service. Regulation 17.
Regulation: Regulation 17
Should-do action 9 of 9
Should do
Well-led
The service should ensure that use of CCTV in the clinic meets national information management standards. Regulation 17.
Regulation: Regulation 17

Location details

CQC ID: 1-10808926160
Local authority: Birmingham
Region: West Midlands

Inspection report

Type: Comprehensive inspection
Date: 13 November 2023
Rating: Requires Improvement
Actions: 9 should-do
AI-extracted 17 Feb 2026