John Sullivan Dental Practice Limited

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 carein accordance withthe relevant regulations.We will be following up on our concerns to ensure the providerhad made the required improvements.

During ourinspectionof 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.

Thisresulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in thedetailedfindings 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.

Systems and processes were not always working effectively, as a result, the inspection highlighted issues and omissions. Some areas requiring improvement were acted on immediately, but there were still issues to be addressed.

Although the practice’s governance system included policies and procedures, which were accessible to staff, there was limited evidence that these had been reviewed on a regular basis, and some were not reflective of current best practice guidance.

Governance systems and processes for identifying and managing risks were not always effective. For example, our inspection highlighted ineffective oversight of processes related to health and safety, sharps, Control of Substances Hazardous to Health, medical emergency equipment checks, environmental cleaning and infection prevention and control compliance, radiation protection, fire safety and safeguarding procedures.

The practice had some systems and processes for learning, quality assurance and continuous improvement. However, these were not always working effectively to drive required improvement, as they had not identified shortfalls highlighted during the inspection. Clinical record audits and anti-microbial audits were not carried out as recommended in best practice guidance.

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

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. Electronic devices were used for patients to complete documents, for example their consent forms and medical histories.

Staff had clear responsibilities, and systems of accountability and there were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

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.

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.