UK Smiles Dental Practice Limited - Romford

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• 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 concerns related to:

the safety of the premises including- fire, legionella, electrical and gas, management of prescribing and dispensing, recruitment, and training, X-ray equipment, The Control of Substances Hazardous to Health Regulations (COSHH), lack of disability discrimination audit (DDA) and lack of oversight.

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.

the registered person had ineffective systems or processes to enable them 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 did not have effective systems to maintain records as are necessary to be kept in relation to persons employed. This included information relating to the requirements under Regulations 4 to 7 and/or Regulation 19 of this part (part 3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Some systems and processes in place were ineffective for identifying and managing all risks, issues and performance. The oversight of the practice did not ensure the systems and processes were embedded in the day-to-day running of the practice.

The inspection highlighted some significant issues and omissions. For example, we found concerns relating to the safety of the premises and equipment, safe and effective staffing, recruitment of staff and training, legionella and fire safety, referrals, and the management of medicines.

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 was no evidence available to confirm that the provider is registered with the Information Commissioner’s Office (ICO).

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), however at the time of the inspection all cameras were not in working order as they were due to be removed and upgraded.

The provider described the processes in place to investigate incidents and accidents and told us that safety alerts were received via emails.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. The provider stated that a DDA had been completed; however, no evidence was provided to support this.

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

Staff had told us they had clear responsibilities; however, this was not always reflected during the inspection. This was because we found certain processes to be absent, unclear and not always in line with guidance and regulatory requirements.

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, “feedback regarding appointment scheduling and workflow has been implemented to improve efficiency and patient experience” as stated by a staff member.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, one stakeholder commented that “enhancing appointment availability during peak times could further improve patient access.” The provider told us they now offered flexible appointments across both locations.

The practice had taken steps to improve environmental sustainability. For example, administrative and clinical processes, including radiograph were digitised.

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.