London Dental House and Medical Clinic

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.

The registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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 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 that there was ineffective leadership and a lack of ongoing oversight which impacted on the practice’s ability to deliver safe, high-quality care.

Systems and processes were not always embedded, and the inspection team highlighted significant issues or omissions. The provider had taken some immediate action but there were still shortfalls to be addressed.

We were not assured the provider and registered manager had sufficient clinical oversight. Leaders were unable to demonstrate an awareness of the nature of bookings and treatment provided, and whether these were booked appropriately for the staff member’s role, competence and experience. In addition, they were not aware of the issues around the absence of clinical records the inspection team had identified.

The practice had a governance system that included policies and procedures. Improvements were needed to ensure that records in relation to the management of regulated activities were readily available and easily accessible to all members of staff and those who would need to review them.

There were no systems and processes to actively seek views, experience and feedback of relevant people. Staff did not gather feedback from patients, the public and external partners and did not demonstrate a commitment to acting on feedback.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records.

We were told that there were no accidents or incidents within the practice in the last 12-months. We saw processes and relevant documentation for investigating incidents and accidents were available if required.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

The practice had not received any complaints in the last 12-months. The practice manager told us that complaints would be acknowledged and investigated in a timely manner and outcomes discussed to share learning for development. In response to our feedback, the practice translated their complaints procedure to a language specific to their patient demographic and displayed this in the waiting room.

Staff feedback was obtained through informal discussions. Improvements could be made to ensure practice updates, policies and procedures were discussed in regular meetings and staff were encouraged to offer suggestions for improvements to the service.

The practice had taken steps to improve environmental sustainability. For example, they segregated waste and used digital records which reduced waste.

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.