Dr Browns 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

During our assessment of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. We also 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.

This resulted in a breach of Regulation 17, Good Governance 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 practice had a governance system that included policies and procedures; however, these were not always reviewed on a regular basis and were not easily available to staff.

Not all systems and processes were effective or embedded and the inspection highlighted some issues and omissions. Areas requiring improvement were acted on immediately.

Staff were aware of the importance of protecting patients’ personal information. Paper 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.

Processes for continuous improvement needed reviewing. We found audits did not identify risks we found during our assessment such as the quality of clinic records and some infection control issues. Infection control and radiography audits needed to be carried out every 6 months rather than yearly according to recognised guidance.

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

The provider would benefit from ensuring staff have clear responsibilities and systems of accountability to support good governance.

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.

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

The practice had taken steps to improve environmental sustainability.

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.