G K Ooi & Associates - Kennington Road

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 that: • 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 timely maintenance of premises and equipment, prescription security, storage of dental care records, radiography, and out of hours provision. 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.

During the inspection we found staff to be open to discussion and feedback. The provider admitted that some equipment and premises maintenance had been carried out reactively as a result of the announcement of assessment and there was a lack of proactive maintenance carried out to comply with the regulations. The provider’s oversight of regulatory requirements was ineffective. 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. 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 public and external partners. For example, they received online reviews and responded to these appropriately.

During the inspection process, some information and evidence was not present and needed to be requested from staff. In addition, some processes had not taken place, such as the registration with HSE for the use of ionising radiation, and with the Information Commissioner’s Office for processing personal data. Following the inspection, we saw that these had been obtained. Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded in the day to day running of the practice. This assessment highlighted some issues and omissions such as relating to fire management, equipment and premises, hazardous substances, infection prevention and control, waste management, record keeping staff training and radiography. The practice had an ineffective governance system which included some policies, protocols and procedures that were accessible to all members of staff. These were not reviewed effectively on a regular basis as they alluded to out-dated guidelines. For example, the general health and safety risk assessment referred to guidance originally issued by the National Radiological Protection Board in 2001 and were withdrawn in 2020. The whistleblowing policy signposted concerned staff to Public Concerns at Work which ceased to exist in 2018. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. The practice should ensure that where appropriate, audits have documented learning points and the resulting improvements can be demonstrated. The latest record keeping audit had not identified that any improvements were required, contrary to our observations.

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.