Clover House 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.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Good governance. You can find more details of our concerns in the detailed findings below.

We will be following up on our concerns to ensure the provider had made the required improvements.

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 was not providing well led care and treatment.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. The systems and processes in place at the time of our inspection, did not give the provider the level of governance and oversight required to ensure effective risk control, management and mitigation, and did not support a culture of continuous improvement.

Systems and processes in place were not embedded. The inspection highlighted some significant issues or omissions. We found:

• Systems in place to manage checks on water temperatures for the control of Legionella were ineffective.
• Oversight of processes in the decontamination room were ineffective.
• Systems to manage medicines in the practice were ineffective. Security of medicines kept in a fridge was insufficient.
• There was no antibiotic audit in place in the practice.
• Systems and processes to address identified risks were ineffective.
• Governance around required registrations, for example, with MHRA were ineffective.
• Systems to identify gaps in record keeping, for example, in staff records, were ineffective.

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 receiving and acting on safety alerts.

The practice had systems and processes for quality assurance in terms of clinical audit, namely patient record audits and radiography audit. We saw this was carried out remotely by a team overseas. When asked about audits, it appeared that they had not been discussed in practice meetings to support learning.

Concerns and complaints were responded to appropriately.

Staff feedback was obtained through meetings and informal discussions. Staff we spoke with were happy in their work at the practice.

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.