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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 20 September 2024.

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, and there was effective leadership that supported the practice to deliver care in line with the relevant regulations.

The registered manager demonstrated a clear understanding of their role and responsibility in relation to the day-to-day management and oversight of the service, including compliance with the legal requirements and relevant guidance.

There were systems in place to ensure staff had clearly defined roles and responsibilities. The registered manager and staff were clear about who had the overall responsibility to oversee recruitment, fire safety, premises and equipment maintenance, the overall management of risk, continuous improvement and management of medical emergencies.

The practice held monthly clinical meetings and quarterly governance meetings to ensure effective oversight of clinical standards, risk management, and regulatory compliance, and to facilitate the timely review and dissemination of evidence-based guidance, policies, and learning across the team.

The information and evidence presented during the assessment was clear and well documented.

The practice had an effective governance system. Protocols and procedures were accessible to all members of staff and policies were service-specific and subject to regular review.

The practice had internal closed-circuit television (CCTV) signage to inform patients and visitors of the presence of CCTV cameras and the CCTV policy was up-to-date. A data protection impact assessment had been completed, and evidence was available to demonstrate that the service was registered with the Information Commissioners Office.

A disability access audit had been undertaken, with a corresponding action plan in place to support continuous improvements in accessibility.

There were effective processes for identifying and managing risks, issues and performance. The practice had implemented improvements in relation to the management of fire safety, Legionella, infection prevention and control, control of substances hazardous to health (COSHH), medical emergencies, sharps safety, radiation protection, lone working and recruitment.

Incidents and accidents were reported internally to ensure information was shared appropriately and learning was embedded across the team.

The practice had effective systems and processes for learning, quality assurance and continuous improvement. There were plans in place for the regular auditing of the dental side of the service. Staff understood what data should be included in these audits and how reviewing outcomes can support the identification and mitigation of risks to quality and safety.

Overall, the practice had strengthened its systems and processes for assessing, monitoring and mitigating risks as well as for overseeing and continuously improving the quality and safety of the service provided.

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.