West Earlham Dental Health 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 inspection of this key question, we found the registered person had some ineffective systems or processes to enable them 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 particular, relating to fire and electrical safety, sharps safety, emergency medicines and equipment, Control of Substances Hazardous to Health (COSHH) and Legionella.

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.

We saw that processes in place were ineffective for identifying and managing all risks, issues and performance, in particular regarding the management of fire, electrical safety, emergency medicines and equipment, legionella, sharps safety and the control of substances hazardous to health (COSHH). Improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records.

The practice had installed closed-circuit television to improve security for patients and staff. Some policies and protocols were in place. Following this feedback, we saw that the practice completed a Data Protection Impact Assessment.

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

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. Improvements could be made to ensure complaints were acknowledged within an acceptable timescale, as the complaints information was unclear. The complaints policy on display stated a 3 working day response, while the staff policy stated 10 working days. Following feedback, the complaints information had been updated and was now consistent.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings 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.

The practice gathered feedback from patients and responded accordingly.

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.