South Ealing 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.

During our inspection of this key question, we found the registered person had ineffective systems and 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. In particular, relating to fire safety, recruitment procedures, medical emergencies in relation to sedation, equipment and premises maintenance and governance and management.

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.

Processes for identifying and managing risks were mostly effective, however, we identified issues with recruitment procedures and fire safety. The registered manager has been responsive to our concerns and is addressing them.

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

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, the radiography audit reviewed 10 X-Rays rather than the recommended 100. The antimicrobial audit was not in line with current guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

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.

We noted innovative approaches to providing person centred care. For example, patients did not necessarily see 1 dentist but were booked in according to the treatment they required and the dentist best suited to provide it. This also gave dentists the opportunity to do more of the procedures they enjoyed most.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys, 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. For example, to improve communication, role-specific messaging groups were created as well as a group for the whole practice. Morning huddles were also introduced.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, paediatric appointments were prioritised during school holidays. Improvements had been made to the patient consent process regarding work-experience students observing treatments.

The practice had taken steps to improve environmental sustainability. For example, using energy-saving equipment, recycling, and adopting a digital workflow to reduce paper waste.

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.