Castle Street 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.

During our assessment of this key question, we found:

a lack of systems or processes that enabled the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. Where processes were in place, they were not always working effectively.

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 provider did not always operate effective systems and processes to ensure they assessed and monitored their service against and in compliance with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a lack of leadership and oversight at the practice. Systems and processes were not always embedded, and the assessment highlighted some significant issues and omissions. The provider had taken immediate action for some of the issues identified, but there were still significant issues to be addressed.

There were ineffective processes for identifying, monitoring and mitigating all risks which arise from the carrying on of the regulated activity. In particular, the management of risks related to Legionella, infection prevention and control, hazardous substances, clinical waste, sharps safety, medical emergencies, stock control, environmental cleaning, radiation protection, health and safety in the workplace, and fire safety.

The governance system in place had required policies and procedures missing and unavailable for staff to access, for example the infection prevention and control policy and documentation relevant to substances hazardous to health. There was no evidence the practice’s policies, protocols and procedures in place had been reviewed on a regular basis and some were not reflective of current best practice guidance.

Safeguarding procedures were ineffective, and the provider had a lack of oversight of staff training and knowledge of safeguarding. Information available to support staff with safeguarding was out-of-date or newly implemented and not embedded. Staff had not received their safeguarding training at the required level and intervals at the time of our assessment, although this had been completed shortly after. The lack of governance processes to support staff with safeguarding was highlighted in the lack of staff’s safeguarding knowledge.

The provider could not provide sufficient assurance of the safety and effectiveness of the premises, and all equipment used in the carrying on of the regulated activity. There was no Electrical Installation Condition Report available, previously known as fixed wiring check, and a health and safety risk assessment had not been carried out, which is a requirement under the Management of Health and Safety at Work Regulations 1999. We noted damage to floors and equipment that had not been risk assessed, or measures introduced to remove the risks to people. In addition, non-clinical rooms were cluttered with combustibles stacked at height. X-ray equipment had not been serviced since 2007 and radiography audits were being carried out infrequently. The last radiation audit was completed in 2022.

The practice did not have systems and processes in place for learning, continuous improvement and innovation.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records and complied with General Data Protection Regulations. However, we saw paper patient records were not always stored securely.

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 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.