Watford Smiles - 107 Hempstead 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 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. 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 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. For example, some concerns relating to the safe management of prescriptions and medicines were acted on immediately. Staff told us there was strong leadership with emphasis on people’s safety and a positive experience of the practice for patients. 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. Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service. However, we were told that these were not always listened to and acted upon, where appropriate. Staff stated they felt respected and valued. They were proud to work in the practice. We saw the practice had some processes to support and develop staff. However, not all staff felt they were provided with appropriate training to fulfil their role. The practice staff demonstrated a transparent and open culture in relation to people’s safety. Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, through online reviews. The practice had taken steps to improve environmental sustainability. For example, they segregated general waste and used digital records where possible.

Systems and processes were not all embedded, and there was a lack of oversight and governance processes relating to the provision of regulated activities. In particular, with regards to radiation and fire safety. The information and evidence obtained for the assessment was not always clear, well documented and available on the day of the assessment. We saw the processes for identifying and managing risks and performance were not always effective. Improvements were required to improve the risk management systems for monitoring and mitigating the risks around medicines management, fire and radiation safety. The practice had systems and processes for learning and quality assurance. This included undertaking audits according to recognised guidance. However, these audits were not always effective in bringing about improvement in the practice. However, the practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. Relevant policies and protocols were in place for the use of closed-circuit television. 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. 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 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.