Ashley Down Dental Care

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• 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 the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided.

We also 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.

Improvements were needed to the oversight of the practice and to ensure information about systems and processes were embedded in the day to day running of the practice.

Staff feedback was obtained through informal discussions.

A business continuity plan was available.

Audits were carried out, but not effectively.

Staff had carried out a disability access audit in November 2024, but they did not provide us with an action plan to indicate whether any they had identified areas they could improve on.

We saw that audits for infection prevention and control were last carried out in May 2024 and not every 6 months as per guidance.

Radiography audits were not carried out 6 monthly in line with College of General Dentistry guidelines. The most recent radiography audit we reviewed, dated June 2024, was not fully completed to include analysis, outcomes or plans.

The practice had systems to review and investigate incidents and accidents. However, they did not have a general data protection (GDPR) compliant accident book available to record accidents.

The practice had systems in place to respond to concerns and complaints appropriately; however, the patient complaints procedure was displayed in an area of the waiting room that was difficult to access.

Safeguarding information was not readily available to staff.

The practice was not signed up to receive patient safety alerts relevant to dentistry. This was remedied on the day of inspection.

The practice had closed circuit television (CCTV). A CCTV privacy impact assessment was not available. CCTV contact details of the data controller were not available for patients and visitors. CCTV warning signage was not prominent for people entering the practice.

The window blind in the public facing aspect of the building on the first-floor treatment room was not used effectively to protect the privacy and dignity of patients who sat in the treatment chair.

The practice could not confirm that any external laboratories used to provide dental appliances for patients were registered with the Medicines and Healthcare products Agency (MHRA).

Policies and procedures were stored on the provider’s computer, which meant they were not readily accessible to all staff. The practice could not evidence that any updates to policies were shared with staff.

This inspection highlighted a number of issues and omissions such as those relating to fire safety, equipment and premises, hazardous substances, infection prevention and control, waste management, staff recruitment, training and legionella management.

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.