The Park Row 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:

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.

The registered person did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed. This included information relating to the requirements under Regulations 4 to 7 and/or Regulation 19 of this part (part 3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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, but these were not effective.

The inspection highlighted significant shortfalls in governance and documentation to provide sufficient oversight and enable the provider to assess, monitor and improve the quality of the service.

Shortfalls included ineffective or lacking systems and documentation for checking emergency medicines and the safe management of medicines, competence and training of staff, adherence to infection prevention and control and recruitment policies, and the quality of patient records. We also highlighted where recommendations had been made in external specialist reports, action to address these had not been done in a timely manner.

Processes were not effective to identify and manage risks. The provider received safety alerts, but we saw these emails had not been opened.

During the inspection, the provider and staff were open to discussion and feedback. They were honest and open about systems and records that were lacking, or where they did not know the whereabouts of policies and documents we requested to see. They demonstrated a very caring attitude for patients, many of whom they had treated for many years, and had acted with good intentions to recruit staff and volunteers to ensure that patients could continue to receive care but had not understood the risks relating to this.

Areas requiring improvement were acted on immediately after the inspection. The provider submitted evidence that the shortfalls highlighted during the inspection were being addressed and new governance systems implemented. These were yet to be embedded.

We signposted the provider to resources to support them to implement processes for learning, quality assurance and continuous improvement, and to undertake audits according to recognised guidance.

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 provider had systems to respond to incidents, concerns and complaints.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. We observed positive interactions between staff and patients both in person and on the telephone. Staff displayed an understanding of patients’ needs and showed warmth and compassion to patients.

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.