175 Fore Street Edmonton London

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider. At the time of the assessment there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered. During our assessment of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided and a lack of systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. This resulted in a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

While we found staff to be open to discussion and feedback, there was ineffective leadership which impacted the practice`s ability to deliver care in line with the fundamental standards. We were not assured that the registered persons understood their role and responsibility in relation to the day-to-day management and oversight of the service. They lacked sufficient understanding of the legal requirements and relevant guidance. When we asked about the recruitment process, the responsible person was unable to set out the requirements as included in the relevant legislation. They did not know where relevant information in relation to recruitment, staff training or servicing documentation for the premises and equipment were kept. There were no systems in place to ensure staff had clear roles and responsibilities. The responsible person and staff were unclear who had the overall responsibility to oversee recruitment, fire safety, premises and equipment maintenance, the overall management of risk and continuous improvement and management of medical emergencies. The information and evidence presented during the assessment was not clear and well documented. The practice did not have an effective governance system. Protocols and procedures were not accessible to all members of staff and policies were not tailored to the service or reviewed on a regular basis.

The practice did not have internal Closed-Circuit Television (CCTV) signage to inform people about the presence of CCTV cameras and the CCTV policy was not up to date. We did not see evidence that a Data Protection Impact Assessment had been completed or evidence to demonstrate that the service was registered with the Information Commissioners Office. The practice did not carry out a disability access audit and there was no action plan to continuously improve access to patients. There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with fire, medication prescriptions, Legionella, infection prevention and control, control of substances hazardous to health (COSHH), medical emergencies, sharps, radiation safety, lone working and recruitment. The practice did not ensure that incidents and accidents were reported internally, so information could be shared with staff to promote learning. We noted an incident documented in a patient’s record. However, we could not find records that this incident had been centrally recorded, reviewed and acted upon. The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. Regular auditing of the dental side of the service was not being carried out. There was a lack of understanding of what data should be included in these audits and how a review of processes could enable the provider to identify where quality and safety were being compromised. The provider could not demonstrate that they carried out dental service specific infection prevention and control, radiography, record keeping and antimicrobial prescribing audits to support continuous improvement of the care provided to service users.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.