Imperial Dental - Stroud

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 ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided and they failed to maintain records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activity or activities. In addition, there was a lack of 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, 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 provider’s systems and oversight of regulatory requirements were ineffective. This inspection identified concerns relating to their risk management protocols, staff recruitment procedures, ongoing staff training and quality assurance.

Auditing systems required improvement. Radiography audits were not effective in identifying or addressing issues with equipment.

The disability access audit did not fully reflect the practice’s accessibility needs and required updating. We discussed with the leadership team ways to enhance audit processes to include clear learning points and action plans where applicable to demonstrate resulting improvements.

Insufficient oversight of the premises and equipment meant that the system in place to ensure actions were carried out was not effective, resulting in minor damages and recommendations remaining unaddressed for extended periods.

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.

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

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff feedback was obtained through ad hoc meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and generally acted upon.

The practice gathered feedback from patients, the public and external partners, 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.