Kendal Dental and Implant Centre

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.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Good governance.

You can find more details of our concerns in the detailed findings below.

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 was not delivering well-led care and treatment services.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, these were not consistently followed and adhered to.

Staff with lead roles did not have sufficient knowledge and experience to deliver extended duties. There was no system in place to effectively identify and address this. Inspection findings indicated that leadership oversight at the practice was insufficient. There was a lack of evidence demonstrating that those responsible had the necessary training, experience, and competence to manage daily operations safely. This contributed to inconsistent leadership across the team

Governance processes in place did not adequately support the practice to oversee and make improvements.

Systems and processes were not embedded. As a result our inspection highlighted issues and omissions.

The provider was receptive, co-operative, and was transparent when we discussed our findings with them. We were given assurances that all areas requiring improvement would be acted on immediately.

The practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities, were ineffective and had not identified the issues highlighted by our inspection, including but not limited to:

• Levels of training and knowledge of staff with extended duties, for example the Radiation Protection Supervisor (RPS)
• The management of the decontamination room environment
• Protocols in place to support reduction in injuries from sharps
• Patient communications on who is providing treatment; and
• The scope of treatment provided by therapists and clear information if referrals are necessary
• Management of medicines
• Recruitment records
• Protocols for visiting dental professionals
• The condition of the electrical wiring in the practice and the lack of response to reports highlighting this
• Systems in place to receive and share clinical updates and safety alerts.

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.

The practice had some systems and processes for learning, quality assurance and continuous improvement. For example we saw audits carried out in accordance with recognised guidance, but these were not always reflective of the practice, for example, those related to IPC and antibiotic prescribing.

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

The practice gathered feedback from patients and responded accordingly.

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.