Holloway House Dental Surgery

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 has made the required improvements.

During our inspection of this key question, we found the registered person had ineffective processes to enable them to assess, monitor and improve the quality and safety of the services being provided.

The registered person had not implemented protocols for the use of closed-circuit television cameras considering the guidelines published by the Information Commissioner’s Office.

This resulted in a breach of Regulation 17, Good Governance.

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.

The provider’s oversight of regulatory requirements required immediate improvement.

Systems and processes were not embedded among staff which highlighted a number of issues which included, control of substances hazardous to health, Legionella, equipment maintenance, radiography, infection prevention and control, NHS prescription management and fire safety management.

The practice did not have adequate information available for patients who wished to feedback concerns and complaints.

The management of accident records and discarded patient information did not comply with General Data Protection Regulation requirements.

Systems and processes were not in place for the use of closed-circuit television (CCTV).

A ground floor treatment room was overlooked by a pavement. Window coverings were not in place to protect the patients’ privacy.

Radiography audits did not follow current guidance and legislation.

The most current infection prevention and control audit did not reflect current practice.

There was no evidence available to confirm the practice gathered feedback from staff through meetings or completed surveys they received from patients.

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.