East Finchley Smiles

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 the provider had made the required improvements.

During our inspection of this key question, we found:

The registered person had ineffective systems or processes to enable them to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

The registered person had systems or processes in place that operating ineffectively in that they failed to enable the registered person to ensure that accurate, complete and contemporaneous records were being maintained securely in respect of each service user.

The registered person did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activities.

These concerns were in 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 detailed 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.

We found staff to be open to discussion and feedback. Where the inspection highlighted issues, the practice took some action to address these concerns immediately after the inspection.

We found that the provider demonstrated appropriate values and a commitment to delivering high‑quality, sustainable services. However, these were not consistently underpinned by effective systems and processes. Inadequate oversight of infection prevention and control procedures, the lack of robust recruitment processes, and insufficient governance arrangements relating to conscious sedation - impacted the effectiveness of the service in meeting regulatory requirements.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

Processes were in place for investigating incidents and accidents, and for receiving and acting on safety alerts. However, improvements were needed to ensure processes for identifying and managing risks were effectively embedded within the practice.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.However, the auditing process required improvement to ensure it effectively identified areas where infection prevention and control procedures were not in line with current guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff told us they had clear responsibilities; however, this was not always reflected during the inspection. This was because we found certain processes to be absent, unclear and not always in line with guidance and regulatory requirements.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. The practice had recently appointed a manager who was in the process of arranging annual appraisals for all staff members.

The practice gathered feedback from patients and responded accordingly. Improvements should be made to ensure that structured patient satisfaction surveys are undertaken consistently, and that responses are systematically analysed for trends to support ongoing quality improvement.

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.