Dental Surgery

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 found 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. In particular, relating to the management of fire safety, electrical safety, sharps safety, control of substances hazardous to health (COSHH), recruitment, continuing professional development (CPD) oversight and the management of medicines.

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 saw that there were ineffective processes in place for identifying and managing all risks, issues and performance, in particular regarding the management of fire safety, electrical safety, sharps safety, COSHH, recruitment, continuing professional development (CPD) oversight and the management of medicines. Improvements were needed to the oversight of the practice’s policies and procedures to ensure that it was consistently well-led for patients and staff.

The practice had a governance system that included policies and procedures, which were accessible to staff. However, we saw that these were not always reflective of the practice. Following this feedback, the practice told us these policies and procedures would be updated. The practice should improve the arrangements in place to ensure good governance and leadership can be sustained in the longer term.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records. However, historic paper records were not stored securely and did not comply with General Data Protection Regulations. Following this feedback, we saw that arrangements had been made for their safe disposal.

Concerns and complaints were responded to appropriately.

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.

The practice gathered feedback from patients and responded accordingly.

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.