Willerby Dental Care 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 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:

Not all systems and processes worked effectively to enable the registered person to assess, monitor and improve the quality and safety of the services being provided. There were some systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk, that were not always working effectively.

There were ineffective 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 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 however they were not always reviewed and updated on a regular basis.

Systems and processes for identifying and managing risks were in place. However, these were not always working effectively and were not always in line with best practice guidance.

The inspection highlighted areas that required improvement, relating to the management and oversight of safeguarding, recruitment documentation, staff training, COSHH, clinical audits, Legionella and infection prevention and control. The provider took immediate action to address gaps in governance processes. We will follow up with the provider to assess how well these improvements are embedded at a follow-up inspection.

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.

Most policies and protocols were in place for the use of closed-circuit television (CCTV), a data protection impact assessment (DPIA) had not been carried out for the CCTV. The practice carried out the DPIA and submitted evidence following the inspection.

There were effective processes for investigating incidents and accidents. The practice were also signed up to receive patient safety alerts and had an effective process to action alerts relevant to the practice.

The practice's systems and processes for learning, quality assurance and continuous improvement were not always working effectively. The practice had undertaken audits. However, these were not always reflective of what we saw on the day of inspection and the frequency was not in line with recognised guidance.

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.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled and turned lighting and equipment off when not in use.

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.