The Lytham Dental Clinic

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.

During our inspection of this key question, we found:

the registered person had ineffective systems or processes that failed 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.

This resulted in a breach of Regulation 17 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.

The current system of policies and governance did not support the practice to ensure good governance and leadership was in place. The recruitment policy was not followed. The safeguarding policy and process lacked information to support the team to identify and quickly act on any concerns. Information was not always easy to find when requested.

The practice was in the process of significant building renovations and refurbishment which had improved access and facilities for wheelchair users, and improved facilities for staff. We were told some documentation had been removed from the practice during this process and placed into secure storage.

During the inspection, the provider was open to feedback, and evidence was sent to assure us the areas requiring improvement were being acted on immediately. They demonstrated a commitment to continuing the work and engagement with staff and external organisations to make further improvements.

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.

The processes for identifying and managing risks were ineffective. In particular, Legionella, fire safety, electrical safety and radiography.

There were systems for staff to report incidents and accidents, and for receiving and acting on safety alerts. We highlighted completed accident forms should be held securely, and the documentation of investigating and learning from significant events should be improved to avoid reoccurrence. For example, a recent significant event highlighted there were steriliser records missing, but did not specify what.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.Audits of patient care records should include conclusions and action plans. We also highlighted the benefits of auditing the use of antimicrobials and signposted them to resources to support this.

Concerns and complaints were responded to, and a log was maintained to track the progress of these. However, we were not assured of its effectiveness. For example, we reviewed where complaints had been received, and the practice did not always respond to further emails where dissatisfaction with the process was expressed.

Staff feedback was obtained through meetings and informal discussions. Staff highlighted this wasn’t always listened to and acted upon, where appropriate.

Feedback from patients, the public and external partners was collected to which the practice responded.

The practice had taken steps to improve environmental sustainability. For example, reducing the use of paper and minimising use of electricity where possible.

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.