Archived: Sydenham 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 they have been put right by the provider.

During our assessment of this key question, we found lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also 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 Regulations 12, 17 and 18 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.

There was an established staff team, who we found to be open to discussion and feedback.

Feedback from staff was obtained through informal discussions. There was no documentation to demonstrate discussions held. Staff were encouraged to speak out and said that the provider was supportive and kind. Staff stated they felt respected, supported and valued. They were proud to work in the practice. However, the practice did not have effective processes to support and develop staff with additional roles and responsibilities.

Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, the NHS Friends and Family Test was available for patients to complete as well as a suggestions box in the waiting area.

Systems and processes to support effective governance and oversight were not embedded. Where the assessment identified areas which required improvement the provider was responsive to ensure that some of these issues were acted on.

There was scope for improvement to the practice’s governance system. During the assessment, information and evidence was not always available. Some of the policies seen were not fully completed or required updating, other policies such as Duty of Candour were not available. We also noted that staff were not working in accordance with some of the practice policies, for example the recruitment and equality and diversity policies. Policies were reviewed on a regular basis. We found that these were not always effective in ensuring governance, oversight and risk mitigation tasks were completed in line with guidance.

Systems to ensure that audits were completed in line with guidance were not effective. We found that information was available for infection prevention and control audits, although these were not completed at the frequency recommended in relevant guidance. The practice was not completing antimicrobial prescribing, disability access or X-ray audits.

There were no recruitment files on the premises, so the provider was unable to provide evidence that the required pre-employment information was available for all staff.

Oversight procedures for completion of the required monitoring checks of the medical emergency equipment and medicines, fire safety systems and NHS prescription pad security were not effective.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information.

Paper records were stored securely and complied with General Data Protection Regulations (GDPR).

We saw there were processes for identifying and managing some risks, although information contained in the practice risk assessment and the fire risk assessment was inaccurate.

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.