Nunneleyhouse 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 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 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 were ineffective.

There were ineffective systems and processes to ensure recruitment procedures were in line with legal requirements and to ensure ongoing oversight of staff training.

This resulted in a breach of Regulation 17, Good governance and Regulation 19, Fit and proper persons employed.

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.

We saw there were ineffective processes for identifying and managing all risks, issues and performance, in particular regarding the management of fire, electrical safety, waste management, use of radiation, the control of substances hazardous to health (COSHH) and recruitment.

Systems and processes were not embedded and the inspection highlighted several issues. The practice had addressed some of the issues and areas requiring improvement following our inspection.

There were some processes for identifying and managing risks, investigating incidents and accidents, but these were not working effectively. There were no processes in place for receiving and acting on safety alerts. Processes were put in place following our inspection.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.Action plans were required to address the shortfalls identified.

Staff had responsibilities, and systems of accountability to support good governance. However, we saw that these were not always reflective of the practice.

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.