Ealing Dental Care

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. We also found ineffective 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.

the registered person had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office.

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 did not always operate effective systems and processes to ensure they assessed and monitored their service against and in compliance with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a lack of leadership and oversight at the practice. Systems and processes were not always embedded, and the assessment highlighted some significant issues and omissions. The provider had taken immediate action for some of the issues identified, but there were still significant issues to be addressed.

There were ineffective processes for identifying, monitoring and mitigating all risks which arise from the carrying on of the regulated activity. In particular, the management of risks related to Legionella, hazardous substances and fire safety.

The provider could not provide sufficient assurance of the safety and effectiveness of the premises, and all equipment used in the carrying on of the regulated activity. There was no Electrical Installation Condition Report available, previously known as fixed wiring check, and portable appliance testing (PAT) was not carried out.

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. However, on the day of inspection we found computers were left unlocked.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance, however, they were not being consistently completed at the required intervals. We raised this with the practice and were assured this would be addressed.

Concerns and complaints were sometimes responded to appropriately. However, complaints were often not documented. We raised this with staff and were assured that all complaints would be documented appropriately going forward.

Improvements could be made to the practice’s business continuity plan which did not consider various emergency scenarios and how the practice would manage them.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys, 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. For example, staff had requested lockers for their belongings and a staff room to have lunch and relax in, both of which the practice were acting upon with the renovations.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, patients had requested longer appointments and later appointments to fit around school hours which the practice had implemented.

The practice had taken steps to improve environmental sustainability. For example, turning off equipment 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.