Dale of Harley Street Limited

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 breach we found at our inspection on 10 January 2025.

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.

At the inspection on 10 June 2025, we found the practice had made the following improvements to comply with the regulations:

The provider demonstrated commitment to delivering safe, sustainable and high-quality care. They had engaged a compliance consultant to support their efforts in becoming complaint with the legal requirements.

A fire safety risk assessment had been carried out on 22 December 2023 and the recommendations made within the risk assessment had been fully implemented. These included installation of appropriate signage on all fire doors and clear indication of all fire exit routes. In addition, the practice carried out periodic in-house checks of the fire alarm system and the emergency lights and maintained records of these checks. We saw evidence that the fire safety equipment received the required servicing. The practice implemented improved systems to support disabled people to evacuate the premises and staff carried out fire evacuations drills. The management of fire safety was now effective.

The electrical installation condition report was completed on 14 January 2025, confirming that the condition of the fixed electrical installations was satisfactory, with no outstanding recommendations.

A Legionella risk assessment had been carried out on 1 February 2024 and the recommendations made within the risk assessment had been fully implemented. These included monthly hot and cold-water temperature checks and the descaling of fittings.

The practice ensured that all required radiation protection documentation was available and up to date. This included updated local rules and a quality assurance plan to ensure equipment s regularly maintained and serviced in a timely manner.

The practice had assessed the risks associated with lone working, the use of hazardous substances and handling sharps. Appropriate control measures were implemented for each area to mitigate risks.

To ensure ongoing compliance, the practice introduced an annual compliance calendar to schedule required maintenance and checks. Plans were in place for weekly internal audits covering fire safety, radiation safety Legionella control, and COSHH (Control of Substances Hazardous to Health).

The practice had implemented an improved system to ensure staff training was up-to-date and reviewed at the required intervals. They were developing centralised training logs for easier monitoring and the practice had core training sessions scheduled for staff for the second half of the year.

Annual appraisals had been scheduled to review individual achievements and development needs.

Policies and documentation were now organised and easily accessible to all relevant staff. The practice compliance schedule included plans to complete the review of all policies by the end of the year. In addition, the practice was in the process of establishing a governance framework to evaluate policy updates and regulatory compliance.

The practice had improved systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Since the last inspection in January 2025, the practice had undertaken infection prevention and control and radiography audits. These audits were detailed, reflective of the arrangements within the service and included a detailed action plan to drive 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.