Woodley 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 they have been put right by the provider.

During our inspection of this key question, we found concerns around the ineffectiveness of the 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.

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.

Staff feedback was obtained through informal discussions.
A business continuity plan was available.

Policies and procedures were readily accessible to all staff.

The practice had systems to review and investigate incidents and accidents.

The practice had systems in place to respond to concerns and complaints
appropriately.

This inspection highlighted several issues and omissions such as those relating to fire safety, equipment and premises, medical emergencies, sedation, infection prevention and control, staff recruitment, training, and legionella management.

Staff were aware of the importance of complying with general data protection regulations (GDPR) but improvements were needed to ensure completed accident records were managed appropriately.

A GDPR compliant accident record book was not available.

The practice was not signed up to receive patient safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.  We noted that the current infection prevention and control audit did not ensure that, where appropriate, any learning points were documented.

Staff demonstrated an open culture in relation to people’s safety. Staff had clear responsibilities, and systems of accountability to support good governance.

The practice had a milling machine make customized ceramic dental restorations in one visit. The machine was not registered with the Medicines and Healthcare products Regulatory Agency (MHRA).

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.

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

The practice had taken steps to improve environmental sustainability. For example, staff were encouraged to use electronic notes instead of paper notes, to reduce wastage. Used batteries were discarded at a battery recycling facility and printer cartridges were posted to appropriate recycling centre.

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.