Egremont Smile 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. We will be following up on our concerns to ensure the provider has made the required improvements.

During our inspection of this key question, we found:

The registered person had ineffective systems or processes that failed to enable them to assess, monitor and improve the quality and safety of the services being provided.

We also found concerns around the effectiveness 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.

They did not have effective systems to ensure dental records were completed appropriately.

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 oversight of the practice did not ensure the systems and processes were embedded in the day-to-day running of the practice.

The practice had ineffective systems relating to the management of Legionella, equipment, hazardous substances, infection prevention and control, waste management, record keeping, staff recruitment and training.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. Records were not available to demonstrate that audits of radiography and infection prevention and control (IPC) were undertaken according to recognised guidance. In addition, the audits did not have documented learning points and resulting improvements could not be demonstrated.

From the records we were shown, concerns and complaints were responded to appropriately. We discussed with the practice manager the importance of ensuring historic records were retained and available for review.

Staff feedback was obtained through meetings and informal discussions.

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 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.