Orthohemel 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 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 the registered person had systems or processes that operated ineffectively in that they failed to enable the registered person 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 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.

We found staff to be open to discussion and feedback. Where the assessment highlighted areas for improvement these were acted on immediately. The practice staff demonstrated a transparent and open culture in relation to people’s safety. However, improved oversight was needed to ensure there was an understanding of the essential requirements and regulations and that changes made to policies and procedures were embedded. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. However, there was reduced capacity to oversee governance at the location as the practice manager was not based on site. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Staff stated they felt respected and valued but not always well supported. They were proud to work in the practice. Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, through online reviews and a suggestion box. The practice had taken steps to improve environmental sustainability by recycling where possible.

Systems and processes were not embedded, and a number of governance processes were completed either following announcement of the assessment or immediately after. The information and evidence presented during the inspection process was not always clear, available and well documented. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. However, these were generic and did not always reflect the processes in the practice. For example, the sharps risk assessment referred to safer sharps systems that were not in use at the practice and did not include other sharps such as orthodontic wires. We saw the processes for identifying and managing risks and performance were not always effective. Improvements were required to improve the practice's risk management systems for monitoring and mitigating the risks around management of Legionella, medical emergencies, fire safety, infection prevention and control, lone working and for the control and storage of substances hazardous to health. The practice did not have effective processes for the oversight of recruitment and training for staff to reflect their roles. For example, the safeguarding leads in the practice had not undertaken training to an appropriate level, although this was immediately rectified. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service. The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, improvement could be made to include audits in record keeping and to increase the sample size for the radiography audit in line with recommendations.

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.