Aylesbury Dental Health Centre

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 the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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.

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 and were reviewed on a regular basis.

Systems and processes were not always fully embedded or operating effectively. However, the provider was responsive to the concerns identified during the inspection, and many areas requiring improvement were addressed promptly.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and records were stored securely and complied with General Data Protection Regulations.

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

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. This included shortcomings in the completion and follow-up of audits in line with recognised guidance. For example, the radiography audit did not include a documented action plan to demonstrate how findings would be addressed, monitored or reviewed.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We noted innovative approaches to delivering person-centred care. For example, the practice demonstrated flexibility in meeting patients' needs by offering appointments during lunchtime or outside normal working hours where required. The practice also carried out follow-up telephone calls after treatment to check on patients' wellbeing and address any concerns, helping to support a positive patient experience and continuity of care.

Staff feedback was obtained through meetings, huddles 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. For example, staff feedback was taken into account as part of refurbishment works, resulting in improvements to the staff toilet and kitchen facilities.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, following patient feedback, a television was installed within the practice to help enhance the patient experience and improve comfort while waiting for treatment.

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.