Browns Dental Surgery

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 the provider had made the required improvements.

During our inspection of this key question, we found:

Systems and 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 were not effective.

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 detailed 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 noted improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with sharps safety, stock control and medical emergencies. In addition, the system to ensure care and treatment was provided in line with national guidance required improvement.

The inspection highlighted some issues and omissions. The practice submitted some evidence following the inspection to show areas requiring improvement were being addressed. We will follow-up on these improvements to ensure they are embedded.

The provider was open to discussion and feedback to improve the practice. They were open and honest about systems, policies and procedures that required improvements.

Improvements were required for identifying and managing risks, investigating incidents and accidents. In particular, ensuring procedures are consistently followed, including documenting and external reporting in line with legislation where applicable.

The practice received and acted on safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. They had carried out radiography, clinical records, antimicrobial prescribing and infection prevention and control audits. However, the quality assurance processes were not effectively used to improve the quality and safety of the service. The infection prevention and control audit had not been carried out every 6-months in line with nationally recognised guidance.

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.

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 good governance.

Staff feedback was obtained through meetings, surveys, 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 practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible and had installed digital systems to reduce paper usage.

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.