Night and Day Emergency Dentist

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

the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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, 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. We found these were not effective or always accessible to staff and were not regularly reviewed.

Systems and processes to support good governance were not established or embedded. The inspection highlighted a number of issues or omissions.

Evidence that required pre-employment information was sought for all staff was not available.

Records to confirm monitoring tasks to reduce the risk from fire, legionella and infection prevention and control were not always completed in line with guidance. Oversight procedures to ensure these tasks were completed were not effectively or consistently applied.

Records to confirm the availability and effectiveness of fire detection and suppression equipment and medical emergency equipment and medicines were not completed consistently or in line with guidance.

The provider demonstrated a commitment to addressing areas requiring improvement swiftly and submitted evidence of actions taken and in progress.

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

Processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts were not established or effective.

The practice had systems and processes for quality assurance which included undertaking audits.

Concerns and complaints were responded to appropriately.

Systems of accountability to support good governance were not effectively applied.

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.