Dentalcare Winterbourne

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 they have been put right by the provider.

During our assessment of this key question, we found that:

The registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and mitigate the risks relating to NHS prescription management, control of substances hazardous to health, Legionella, disabled access, radiography, infection prevention and control, the use of closed-circuit television and fire safety management.

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 evidence category 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 provider’s oversight of regulatory requirements was ineffective.

This assessment highlighted some issues and omissions relating to NHS prescription management, control of substances hazardous to health, Legionella, disabled access, radiography, infection prevention and control, the use of closed-circuit television and fire safety management.

Systems and processes were not embedded among staff which highlighted a number of issues. We were told the provider was aware of this and was working with the newly appointed practice manager to make 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 (GDPR).

The practice installed closed-circuit television, to improve security for patients and staff. The practice did not have the relevant protocols and procedures in place to ensure its appropriate use.

Security of computers present in public areas did not comply with GDPR requirements. This was addressed during our visit.

The practice had not implemented systems for reviewing and investigating accidents and incidents.

The practice generally had systems and processes for learning, quality assurance and continuous improvement. The practice radiography audit was due in February 2025. Improvement could be made to ensure radiography audits are undertaken at the recommended interval of 6 monthly.

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.

Feedback from patients, the public and external partners was collected to which the practice responded. For example, as a result of poor patient feedback the practice employed staff to support patient’s access via telephone.

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.