The Dentalist Loughborough

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.

At the time of the inspection, there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

During our inspection of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided.

This resulted in a breach of Regulation 17, Good Governance.

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.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, systems and processes were not fully embedded or sufficiently effective. In particular, oversight and management of dental radiography, staff training, medicines, patient records, consent and complaints.

Systems and processes for learning, quality assurance and continuous improvement required strengthening, including undertaking audits according to recognised guidance.

The practice did not always manage concerns and complaints effectively, and a culture of continuous improvement was not consistently demonstrated.

Many of the areas requiring improvement were acted on immediately demonstrating the practices commitment to improving the service for both staff and patients. We will be following up on our concerns to ensure the provider has made the required improvements.

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.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

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 practice had taken steps to improve environmental sustainability. This included recycling and turning lights off when not in use.

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.