Ealing Dental & Medical Stunning Smile Skin 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 they have been put right by the provider. During our assessment of this key question, we found there was a lack of effective 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. In addition, the registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person to assess, monitor and improve the quality and safety of the services being provided and to maintain securely such records as are necessary to be kept in relation to the management of regulated activities. 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 had identified areas which required improvement, these were acted on immediately. The practice staff demonstrated a transparent and open culture in relation to people’s safety. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through meetings and 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. For example, the receptionist had suggested that the practice install a television within the waiting area, where oral health information could be displayed. Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they collected and responded to feedback from patients. This included asking patients to provide online reviews and we saw these were responded to. The practice had taken steps to improve environmental sustainability. They had reduced the amount of paper they were printing by sending out information electronically.

Not all information and evidence required for our assessment was readily available. The practice had a governance system which included policies, protocols and procedures. Not all staff knew where to find them. Most policies had not been reviewed since 2021. Relevant documents were not available for the use of closed-circuit television (CCTV). While a CCTV audit had been completed on 14 February 2024, we were unable to find evidence of a Data Protection Impact Assessment which documented the purpose and assessment of risks associated with the use of CCTV. While there were signs that CCTV was present on the premises, they did not inform patients that it was also within treatment rooms. Following feedback, the service sent a Data Protection Impact Assessment which stated that the CCTV had been removed from the treatment rooms. 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 safe recruitment of staff, infection prevention and control, management of Legionella, radiography, medicines management, sharps procedures, fire safety and for the control and storage of substances hazardous to health. The practice had systems to review and investigate incidents and for receiving and acting on safety alerts. The practice had processes in place to respond to concerns and complaints. Improvements were required to ensure that information on how to make a complaint included contact details of all relevant organisations to escalate a complaint to if required. The practice had processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Improvements were required to ensure that audits had documented learning points and improvements demonstrated.

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.