University of Bath Dental Centre

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 and had taken into consideration appropriate guidance.

Systems and processes were in place; however, aspects of monitoring, documentation and oversight required strengthening to ensure that all risks were consistently identified, assessed, and mitigated.

We found shortfalls in appropriately assessing and mitigating risks in relation to the control of substances hazardous to health, radiography, medical emergencies, staffing, infection prevention and control, accessibility requirements, continuous improvement, and fire safety management.

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.

Systems and processes were in place; however, aspects of monitoring, documentation and oversight required strengthening to ensure that all risks were consistently identified, assessed, and mitigated.

Areas requiring improvement related to the control of substances hazardous to health, radiography, medical emergencies, staffing, infection prevention and control, accessibility requirements, continuous improvement, and fire safety management.

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

The practice had systems and processes for learning, quality assurance and continuous improvement but were not followed effectively. In particular, the frequency of Infection prevention and control audits and the completeness of radiography audits.

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

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. For example, the practice replaced its dental software, and this was chosen based on staff feedback.

The practice gathered feedback from patients and responded accordingly.

The practice had taken steps to improve environmental sustainability. Staff promote recycling of toothbrushes and toothpaste tubes. Paper is kept to a minimum and recycling is carried out.

We were told about occasions when staff went over and above. One being was when roofing work was planned. Staff identified patients that may struggle with the noise and disruption and contacted them to discuss the impact for them.

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.