Octagon Dental care

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 carein accordance withthe relevant regulations.We will be following up on our concerns to ensure the providerhas made the required improvements.

During ourinspectionof this key question, we found a lack of systems or processes that enabled the registered person to assess,monitorand improve the quality and safety of the services being provided. There was also a lack of systems or processes to assess,monitorand mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

These concerns were in breach of regulation 17, good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 were not assured that the responsible person understood their roles and legal responsibilities to support good governance.

Governance systems were ineffective and had not included sufficient oversight. A system of compliance had been procured but staff did not know how to use the system. We saw that policies to support staff in their duties did not always contain the necessary information or had not been completed. We were not assured that procedures were reviewed on a regular basis.

The information and evidence presented during the inspection was not always accessible or reflective of the practice.

There were ineffective processes for identifying and managing risks, particularly around the risk of fire, Legionella, sharps, hepatitis B, medical emergencies and staff training.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Although audits were undertaken, these were not completed according to recognised guidance. Action is needed to ensure audits of radiography, infection prevention and control, and antimicrobial prescribing are undertaken at regular intervals to maintain or improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be clearly demonstrated.

We saw that documentation in relation to the use of closed-circuit television, in the form of a data protection impact assessment was not available.

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 received patient safety alerts.

There was no evidence to demonstrate that concerns and complaints were responded to appropriately, or that outcomes would be discussed to share learning and for improvement.

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.