Horn Mews Dental Practice

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.

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. However, many of these were out of date, had not been reviewed annually and referred to information and contact organisations that were no longer accurate or relevant.

There was a lack of sufficient governance and oversight to identify and manage various risks, including risks associated with recruitment, medical emergencies, Legionella and fire safety management. Areas requiring improvement were acted on immediately demonstrating the practices commitment to making improvements for both staff and patients. However, there was scope to ensure these systems were embedded within the practice.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, however paper records were not stored securely or complied with General Data Protection Regulations. There was scope to ensure patients reference numbers or identifications were used during external communications.

Relevant policies and protocols were in not place for the use of closed-circuit television (CCTV). There was no signage available in the practice to advise patients they were being recorded.

Systems for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts required strengthening.

Systems and processes for learning, quality assurance and continuous improvement required strengthening. This included undertaking audits according to recognised guidance. Audits of radiography, disability access, record keeping and antimicrobial prescribing were not carried out or were not carried out at the recommended intervals.

Concerns and complaints were responded to appropriately, and outcomes were discussed informally to share learning and for improvement. We noted the complaints protocol contained incorrect contact information which had not been reviewed.

There was scope to ensure staff responsibilities, and systems of accountability were embedded to support good governance.

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