Dale of Harley Street 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 them to assess, monitor and improve the quality and safety of the services being provided. In addition, 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 evidence category findings below. Whilst there are issues to be addressed, the impact of our concerns relate to the governance and the oversight of the risks, rather than a patient safety risk.

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 issues, the practice took some action to address these concerns immediately. We found that the provider had the values and commitment to deliver high quality sustainable services. However, the ineffective management of risks and lack of oversight of training impacted the day-to-day management of the service. 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 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, supported and valued. They were proud to work in the practice. Staff told us how they collected and responded to feedback from patients. The practice had taken steps to improve environmental sustainability. They segregated waste and used digital records, where possible. The practice had information governance arrangements and 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 (GDPR). 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. The practice had not received a complaint in the 12 months prior to our assessment. We were told that complaints would be discussed amongst staff members, so that areas of improvement could be identified and acted on.

The information and evidence presented during the assessment was not always clear and well documented. There were ineffective processes for identifying and managing risks. On the day of assessment, the relevant documentation to demonstrate that radiation equipment was safe to use was not available. Improvements were needed to the management of risks associated with the use of sharps, hazardous materials and lone working. Improvements were needed to ensure that recommendations made in the Legionella and fire risk assessments were actioned within the suggested timeframes. The practice had ineffective systems in place for quality assurance and continuous improvement. The practice did not have effective oversight of staff training. Prior to our assessment staff had not completed training in autism and learning disability awareness, legionella, safeguarding, sepsis awareness, and the Mental Capacity Act 2005. There were no records of annual appraisals, covering individual performance and development needs. The practice had carried out a radiography audit, however this did not have documented learning points and was not suitable to drive improvement. Improvements could be made to ensure the practice completed antimicrobial prescribing audits in line with the current guidance. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. Although date stamps indicated that policies were reviewed annually, they were not suitably updated as some contained out-of-date information. The provider told us that they had now engaged a compliance company that will support them with updating their policies and procedures.

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.