Marble Arch Dental 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 had made the required improvements.

During our inspection of this key question, we found that the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided.

There were also ineffective systems or processes to enable the registered provider to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

In addition, the registered person did not have effective systems to ensure dental records were stored securely.

This resulted in a breach of Regulation 17, Good governance.

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 practice did not have an effective governance system. Systems and processes were not embedded. While there were some policies and procedures which were accessible to staff, these were not sufficient to ensure patient safety and regulatory compliance.

The practice's risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities required improvement. In particular, the risks associated with fire safety, radiation safety, the management of medical emergency equipment and medicines, COSHH, and sharps safety. In addition, improvements were required to the monitoring of staff training and recruitment processes to ensure they complied with legislation.

The practice did not have a business continuity plan, to help identify and plan for anticipated risks to the delivery of the service.

The practice had ineffective systems in place for learning, quality assurance and continuous improvement. The practice did not carry out any regular audits of infection prevention and control, radiography, antimicrobial prescribing or record keeping. The practice had failed to carry out a disability access audit.

Where the assessment highlighted significant issues, the practice took some action to address these concerns immediately. Staff demonstrated an open culture in relation to people’s safety and wanted to demonstrate improvement.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, but paper records were not stored securely to comply with General Data Protection Regulations.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), but these had not been reviewed for several years.

There were processes in place for investigating incidents and accidents, and for receiving and acting on safety alerts.

Concerns and complaints were responded to appropriately. Improvements could be made to ensure outcomes were discussed to share learning and for improvement.

The practice gathered feedback from patients and responded accordingly, and staff feedback was obtained through informal discussions.

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.