Gareth Roberts - 69 Pont Street

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.

During our inspection of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided,

The registered person had systems or processes that operated ineffectively in that they failed to enable them 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.

Some processes in place were ineffectivefor identifying and managing all risks. The oversight of the practice did not ensure the systems and processes were embedded in the day-to-day running of the practice for example the practice did not have oversight of medical emergency equipment to monitor the expiry dates of items in the medical emergency kit. Following the inspection, the practice took immediate action and ordered the missing items and told us they had implemented a log.

The inspection identified several significant issues and omissions. These included concerns about ineffective risk management in relation to sedation, such as the absence of fully contemporaneous sedation notes, incomplete documentation of pre-assessment checks, and a lack of detail regarding the patient discharge process, including the provision of emergency contact information.

In addition, there was a lack of oversight in key safety areas. This included inadequate risk management systems for fire safety, such as missing or insufficient systems to monitor fire safety equipment and no documented evidence of fire evacuation drills. There were also concerns around infection prevention and control procedures, as well as insufficient oversight of staff training. Not all staff were able to demonstrate appropriate knowledge of safeguarding, sepsis, and whistleblowing procedures.

Most of the areas requiring improvement were acted upon immediately following the inspection—for example, improvements were made to staff training.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations. Improvements could be made to ensure the staff accident book complied with General Data Protection Regulation as previous entries made by other members of staff were visible to others.

Improvements were required to the systems and processes for learning, quality assurance and continuous improvement. While audits were thorough and detailed, we found they did not reflect processes in place and were not always undertaken in line with national guidance. For example, the infection control and record keeping audit did not reflect our findings on the day. The antibiotic audit did not align to recognised guidelines.

During the inspection we found staff to be open to discussion and feedback.

The practice had an online governance system that included policies and procedures.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. For example, donating spare toothpaste to the local church for the homeless.

The practice had taken steps to improve environmental sustainability. They recycled where possible and ensured any devices which were not in use were switched off.

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.