Durley Avenue 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 foundthe registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

There were ineffective systems for ensuring that information in the form of policies and procedures was kept up to date, and that staff had read and understood them. Policies were not always reviewed at timely intervals. In response to our feedback, improvement were made to the accessibility of the policies and staff signature log implemented.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records and complied with General Data Protection Regulations. Policies and protocols were in place for the use of closed-circuit television (CCTV), however a Data Protection Impact Assessment (DPIA) had not been completed before installation. In response to our feedback a DPIA has been completed.

We saw that improvements were required to the processes in place to identify and manage risks in relation to fire safety, Legionella and staff recruitment and training.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.However, the practice should ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.

There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

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

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.

Feedback from patients, the public and external partners was collected to which the practice responded.

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.