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 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 breaches found at our inspection on 18 June 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 30 September 2025, we found the practice had made the following improvements to comply with the regulation:

The practice had improved their risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities. Systems and processes were more robust and were becoming embedded.

The practice had made improvements regarding the oversight of the medical emergency kit. Missing items were replaced, and a log had been implemented to monitor expiry dates.

The practice had implemented an effective system for managing patients receiving treatment under sedation. Sedation notes were contemporaneous, pre-assessment checks were documented, and discharge notes were updated to include additional details, such as emergency contact information.

Oversight in key safety areas had improved. This included robust management systems for fire safety, infection prevention and control, and staff training.

The practice had made improvements regarding the systems and processes for learning, quality assurance and continuous improvements. In particular, the antibiotic audit aligned with recognised guidance and the infection control and record keeping audits reflected processes in the practice and included a comprehensive analysis and action plan of the findings.

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.