Clarendon House Dental Centre Ltd

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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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.

Staff were working hard to implement new systems and processes; however, they were not yet fully embedded. The inspection highlighted some issues and omissions, some of the areas requiring improvement were acted on immediately.

The practice had a limited governance system that included policies and procedures, which were accessible to staff and were reviewed. Oversight of systems and processes required strengthening. For example, items of the medical emergency kit were missing and check sheets and logs were not being completed at the required frequency. Evidence was sent following this inspection to demonstrate that this issue had been addressed.

There was a lack of oversight to ensure that the practice’s procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance had been implemented. Water temperature monitoring logs did not demonstrate that hot water was reaching the required temperature. Following this inspection, we received evidence to demonstrate that action had been taken and hot water was now reaching the required temperature.

At the time of inspection, there were limited systems in place for oversight of staff training. We were provided with some evidence following this inspection that staff were up to date with required learning, however we were not provided with evidence to demonstrate that all staff had completed all the required learning. We were given some assurance that a new system would be introduced to monitor staff training going forward.

Systems were in place for staff recruitment, however there was a lack of oversight to ensure that the required information was available on all occasions in line with regulations. We were given assurances that this information would be obtained.

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 some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits, although improvements were required to ensure they were completed in line with recognised guidance. We saw that the radiography audit did not contain the correct sample size. Following this inspection, we were sent an audit which recorded the correct sample size including a summary sheet and action plan.

We found that clinical record keeping audits were not completed. Issues were identified during this inspection regarding information missing from clinical records such as diagnosis, cancer risk ratings and tooth wear risk ratings. These issues would have been identified in a clinical record keeping audit. Evidence was sent following inspection of clinical record audit including summary and action plan.

The infection prevention and control audit was not being completed at the required frequency.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff had clear responsibilities, and systems of accountability to support governance.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

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.