Chiswick Park 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 inspection of this key question, we found 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.

In addition, we found the registered person did not maintain records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activity. In particular, relating to staff recruitment and staff training.

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 had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, systems and processes were not fully embedded. 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, lone working and the management of sharps injuries. In addition, improvements were required to the monitoring of staff training and recruitment processes to ensure they complied with legislation. Improvements were also required to ensure staff feel confident to refer safeguarding concerns to external agencies and that patient referrals to other dental or health care professionals are monitored, to ensure they are received in a timely manner and not lost. We will be following up on our concerns to ensure the provider has made the required improvements, and that good governance and leadership are sustained in the longer term.

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.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.Improvements could be made to ensure that audits have documented learning points, so that resulting improvements can be demonstrated.

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

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 practice had taken steps to improve environmental sustainability. For example, by turning off equipment and lights when not in use.

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.