Leven Vale Dental Practice Also known as Leven Vale DP Ltd

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:

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 were not effective.

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.

There was a lack of leadership and oversight at the practice. Systems and processes were not always embedded, and the inspection highlighted some significant issues and omissions.

Improvements were required to some of the practice’s systems and processes to strengthen management oversight. Systems and processes were not always clear and effective. In particular, improvements were needed in the management of risks related to, infection prevention and control, hazardous substances, clinical waste and environmental cleaning.

Improvements were required to the governance system in place. Policies, procedures and documentation were missing and unavailable to us on the day of our on-site inspection and not readily available for staff to access.

Improvements were required for identifying and managing risks, investigating incidents and accidents. In particular, ensuring that all accident and incidents are recorded with a view to preventing further occurrences and ensuring that improvements are made as a result.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. They had carried out radiography, clinical records, antimicrobial prescribing and infection prevention and control audits. However, the quality assurance processes were not effectively used to improve the quality and safety of the service.

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).

Concerns and complaints were responded to appropriately.

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.