This service is rated as
Good
overall. This is the locations first inspection since registering with CQC in October 2020
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced, comprehensive inspection at The Highgrove Clinic as part of our planned inspection programme.
The Highgrove Clinic is the registered location and the registered provider is The Highgrove Clinic Limited. The clinic provides services for privately funded patients who self-refer to the service.
This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Highgrove Clinic provides a range of non-surgical cosmetic interventions, for example wrinkle reduction injections by botulinum toxin injections (botox) and dermal filler treatments which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. We only inspected elements of the service which fell under our scope of regulated activities, for example minor skin surgeries, hyperhidrosis and bruxism with botox, thread lifts and vasectomies.
The provider has one location at the address above in Bristol. The Highgrove Clinic has two company directors. Care and treatment at The Highgrove Clinic is managed by one of the directors who is the registered manager. We will refer to this person as the registered manager throughout this report. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Vasectomies carried out under this registration and location were also advertised under a separate website known as Bristol Vasectomy Clinic.
The provider and registered manager is a Doctor registered with the General Medical Council and a member of Association of Surgeons in primary care and contributes towards worldwide learning. The other director is a registered dentist and member of the Royal College of Surgeons who works at the service to provide some of the regulated activities. The service also had an administrative member of staff.
The Highgrove Clinic is in the city of Bristol. There is parking made available at the location through gates which is accessible to those with disabilities also. Consultations were provided via an initial telephone call followed by a face to face consultation where required.
We reviewed feedback which had been collated by the service and that was submitted to us during a monitoring call in November 2022. We received 18 “Give feedback on care” forms in the last 12 months.
Our key findings were:
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- The service organised and delivered services to meet patient’s needs. Patients were well informed about aspects of the service provided. The service welcomed feedback.
- There were clear responsibilities, roles and systems of accountability to support governance and management. There were systems for managing risk and issues, however further work was required to review, monitor and embed revised policies to meet the service’s needs.
- Clinical staff held appropriate qualifications and knowledge to provide quality patient care.
The areas where the provider should make improvements are:
- Review and embed health and safety policies to meet the service’s needs and document appropriately.
- Consider the threshold for documentation of incidents including near misses in line with the service policy.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services