Pimlico 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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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 maintained a governance system that included policies and procedures; however, these were not always tailored to the practice's specific arrangements. We also found that records were not organised in a way that supported the efficient retrieval of information during the inspection. Whilst the practice had a compliance system in place, it was not always used effectively to support governance oversight and the management of governance arrangements.

Systems and processes were not always embedded. The inspection highlighted several issues and omissions, some of which were addressed immediately following our feedback. The provider told us they had been responsible for both practice management and compliance-related duties but acknowledged that managing these responsibilities alone was challenging. To strengthen oversight and governance, they told us the role would be shared between two members of staff, with one taking responsibility for clinical management and the other for administrative and compliance functions.

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 processes in place to identify and manage most risks. The provider agreed that arrangements for the management of prescription pads, sharps safety, recruitment, and staff training could be further strengthened. The provider confirmed that actions had been taken to improve these processes following the inspection.

Processes were in place for investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes in place to support learning, quality assurance, and continuous improvement. However, these systems were not always used effectively to identify opportunities for improvement. For example, radiography audits were not consistently undertaken at 6 monthly intervals in line with recognised guidance. We noted that the most recent radiograph audit had been completed in September 2024 and included fewer than 100 images, with no audit having been undertaken to cover the subsequent 6month period.

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

We noted innovative approaches to providing person centred care. For example, the practice offered a range of dental services in one location, enabling patients to access the care they needed in a convenient and coordinated way. The onsite dental laboratory further enhanced the patient experience by supporting timely treatment and reducing the need for additional appointments where appropriate.

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

Staff told us that the provider listened to their views, valued their feedback, and encouraged them to share ideas and suggestions for improving the service. However, some staff felt the team would benefit from more regular practice meetings, as these were infrequent at the time of the inspection. This was recognised by the provider who acknowledged that improvement was required.

The practice told us they gathered feedback from patients, members of the public, and external partners and responded to this as appropriate. However, these processes were informal, and we did not see documented evidence to demonstrate how feedback was routinely collected, analysed, or used to inform service improvements.

The practice had taken steps to improve environmental sustainability. For example, several work processes were digitised including, clinical care records and x-rays. Staff also told us that they were encouraged to recycle and turn 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.