Archived: Ortho Limited t/a Cheyne Walk Orthodontics

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 following concerns: The registered person had systems or processes 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. We also found concerns around the ineffectiveness of the 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. This resulted in breaches of Regulations 12, 17, 18 and 19 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.

The provider did not demonstrate a transparent and open culture in relation to people’s safety. Our findings on the day of our assessment differed from what staff and leaders told us, and there were discrepancies between what staff and leaders said. Staff were not clear about responsibilities, roles and systems of accountability to support good governance and management. Staff stated they felt respected, supported and valued and their feedback was obtained through meetings and informal discussions. However, we were not assured that the practice had effective processes to support and develop staff with additional roles and responsibilities. We identified gaps in staff`s knowledge, including infection prevention and control, safeguarding and medical emergencies. Leadership and oversight were not effective to ensure appropriate changes would be made and sustained. Some of the concerns identified at this assessment were similar in nature to issues identified during previous inspections of the service in March 2013 and March 2017. Leaders were not always present, but staff told us they were accessible remotely. The provider confirmed the 2-week notice leading to the assessment highlighted a lack of oversight and was actively recruiting for a manager. The concerns and complaints system was ineffective. The provider told us they had received approximately 4 complaints within the last 12 months, but copies of these were not available on the day. We reviewed 2 complaints received more than 12 months ago and saw there were no documented actions or outcomes. The practice response did not include appropriate action taken nor outcomes. There was no information available for complainants to take further action if unsatisfied with the practice response. There was no evidence staff discussed complaint outcomes to share learning and drive improvement.

Systems and processes were ineffective and not embedded. The governance system included polices, protocols and procedures and was accessible to all members of staff online. However, some staff did not know where to find them. Many policies had not been reviewed for example, the complaints policy was dated 1 September 2019 and contained incorrect details for escalating complaints. Where the assessment identified areas which required improvement, some of these areas were acted on immediately such as replenishing out-of-date emergency equipment and improving the cleanliness of the practice. There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with fire, Legionella, health and safety, infection control, radiation safety, staff training and recruitment. We were not assured the systems in place to document and learn from significant events and accidents were effective. Staff had not been suitably inducted in the significant events processes. Staff told us and we saw no recorded significant events. However, there had been incidents such as a break in, potential safeguarding referral and a near miss fall that met the significant events criteria. The practice had uploaded safety alerts to a folder accessible to staff on 23 June 2024. This did not include all recent safety alerts. There was no evidence to show how learning from safety alerts and incidents had been actioned or shared across the team to prevent their recurrence. The practice did not have systems and processes for learning, quality assurance and continuous improvement. Audits were not undertaken in line with recognised guidance.

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.