Eyre Street Dental

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 assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided.

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.

The practice staff and provider demonstrated a commitment to developing a transparent and open culture in relation to people’s safety.

We noted that systems and processes were operational at the service but not fully embedded across all the staff team or areas of the service. Where the assessment identified areas which required improvement these were acted on swiftly.

The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. We found that these were not always effective in ensuring governance, oversight and risk mitigation tasks were completed in line with guidance.

Systems to ensure that audits were completed in line with guidance were not effective. We found that information was gathered to develop audits for radiography and infection prevention and control (IPC), but this was not always gathered for individual clinicians or analysed to promote development and improvement. Audits of clinical records and antimicrobial prescribing had never been carried out.

Monitoring of recruitment files did not identify that required pre employment information was not available for all staff.

Oversight procedures for completion of required monitoring checks of the availability and suitability of medical emergency equipment and medicines, fire extinguishers and exits and NHS prescription pad security were not effective.

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 feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service.

Feedback from patients, the public and external partners was collected to which the practice responded.

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.