Barbara Castle Dental Practice - Harlow

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 particular relating to the management of recruitment, fire safety, Legionella, auditing, risk assessments, and ensuring staff had adequate immunity to Hepatitis B.

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.

We saw that not all processes in place were effective for identifying and managing all risks, issues and performance, in particular regarding the management of Fire, Legionella, ensuring staff had adequate immunity to Hepatitis B or an associated risk assessment, auditing and the management of medicines. There were no Health and Safety or Sharps risk assessments in place. Improvements were needed to the oversight and governance 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.

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

Processes for identifying and managing incidents and accidents, and for receiving and acting on safety alerts required strengthening.

The practice had no oversight of regular building testing undertaken by the landlord. This included Fire risk assessments, fire drills, fire equipment testing, legionella risk assessments, water sample testing and their outcomes. There were no records available of a Electrical Installation Condition report.

Systems and processes for learning, quality assurance and continuous improvement required strengthening. This included ensuring audits were undertaken in line with recognised guidance.

Policies and protocols were mostly in place for the use of closed-circuit television (CCTV). However, there was no Data Protection Impact Assessment for the use of CCTV.

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, 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.