Queensgate 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.

At the time of the inspection, there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

During our inspection of this key question, we found a a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality of the services being provided and the provider had failed to maintain securely such other records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activity and the management of the regulated activity.

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.

We found that information and evidence relating to governance and oversight presented during the inspection was not always clear and well documented. The practice’s governance systems were not always effective in supporting to maintain sufficient oversight. There were limited policies, protocols and procedures, and these were not always stored in a way that made them easily accessible to all members of staff.

Systems and processes were not fully embedded. In particular, the practice lacked effective systems for recruitment and training oversight. There were no risk assessments in place for staff who did not have a Disclosure and Barring Service (DBS) check, and photographic identification was missing for some staff members. In addition, improvements were required to ensure compliance with mandatory training, including Safeguarding Adults and Children, Sepsis, Fire Safety, Learning Disability and Autism, and Mental Capacity training.

The practice did not have effective systems and processes in place for learning, quality assurance and continuous improvement. The practice had failed to perform a radiography audit or disability access audit. Both the Ionising Radiations Regulations 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017place a legal responsibility on practices to establish and maintain audits for dental radiology, and a disability access audit is required to ensure compliance with the Equality Act 2010. Further improvements could be made by completing antimicrobial audits.

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 in place for identifying and managing risks, 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.

The practice had taken steps to improve environmental sustainability. For example, recycling where possible, turning off all electronic devices when not in use and storing records electronically.

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.