Hangleton 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 has 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 lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of systems or 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.

This resulted in a breach of Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Leadership at the practice was ineffective as there was a lack of oversight of the day-to-day management of the service. There was no registered manager in post.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement.The provider had a compliance system to support staff with the governance arrangements but we found this was not used effectively. There were gaps in staff training which had not been identified. Overall, the provider had not identified the gaps in their quality monitoring processes.

The processes for identifying and managing risks, were not always effective. In particular, the risks associated with fire, infection prevention and control and staff recruitment.

Although audits were undertaken, these were not completed according to recognised guidance. The practice should take action to ensure audits of radiography, infection prevention and control, record keeping and antimicrobial prescribing are undertaken at regular intervals to maintain or improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated.

Policies, protocols and procedures were in place, but these were difficult to find and were not regularly reviewed. Some of the policies we reviewed did not contain up to date information or had required information missing.

Where the inspection identified areas which required improvement, the provider submitted some information following the inspection. This provided us with some assurance that the provider was implementing improvements. However, evidence is required to demonstrate that any improvements are embedded into the day to day running of the practice.

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.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

Immediately after our inspection, the provider completed a Data Protection Impact Assessment (DPIA). We were provided with a copy which included the required information about the use of CCTV and assessment of risks associated with its use.

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

Concerns and complaints were responded to appropriately. However, improvements were ongoing to ensure that complaints were documented and assessed appropriately.

Staff did not always have clear responsibilities or systems of accountability to support good governance.

Staff feedback was obtained through meetings and informal discussions although there was no evidence that actions and learning points had been addressed.

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