Dental Surgery

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.

Improvements were required to some of the practice’s systems and processes to improve management oversight. The inspection highlighted some significant issues and omissions. The practice acted immediately to reduce the risk of some of these issues.

Improvements were required to the governance systems to ensure policies and procedures were regularly reviewed and easily accessible to staff.

We noted improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire safety, health and safety, stock control, hazardous substances, and staff recruitment.

We noted there was no evidence a health and safety risk assessment had been conducted for the premises and no evidence of key policies and procedures. In particular, a consent policy, a data protection policy, a data protection privacy notice for patients, an infection prevention and control policy, an incident and accident reporting policy, and a business continuity plan. We noted other policies were generic and did not align with the practice’s protocols or were not consistently followed.

We were unable to check concerns and complaints were responded to appropriately as these documents were not available on the day of inspection. Improvements were required to ensure a patients complaints procedure with escalation options was available for patients.

There were no processes for investigating incidents and accidents. We noted there was no evidence of an incident and accident reporting policy, no incidents had ever been recorded, and no accidents had been recorded since 2016.

The processes for receiving and acting on safety alerts were ineffective. In particular, there was no evidence the practice was receiving safety alerts. The practice signed up to receive alerts on the day of inspection.

Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

The practice had some systems and processes for learning, quality assurance and continuous improvement. We noted the infection control audits were not reflective of practice protocols and did not have an action plan to drive improvement. There was no evidence of any radiography audits available to view on the inspection day. The clinical records audits were not reflective of what we found on the inspection day and did not highlight areas of concern.

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. For example, the practice had reduced double booking, so staff had more time for patients.

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

The practice had taken steps to improve environmental sustainability. For example, the practice recycled and reduced paper usage 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.