Riverway Dental 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.

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 mostly embedded. Where the inspection identified areas which required improvement, these were acted on immediately and the provider and staff demonstrated a commitment to addressing all issues identified.

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.

Systems and processes for identifying and mitigating risks, issues and performance were not always clear and effective. There was scope to ensure processes for learning, quality assurance and continuous improvement were improved. Audits of infection prevention and control, antimicrobial prescribing, disabled access and radiography were not fully in line with current guidance and timeframes. We found COSHH and dental sharps risk assessments were undertaken, but were not in line with recommended guidance. There was limited evidence of any outcomes or actions from these audits or risk assessments.

Checks of hot and cold water temperatures, fire drills, medical alerts and checks of replacing equipment in the decontamination area were not always clearly documented. Evidence of periodic testing of the ultrasonic was not in place.

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

Staff had clear responsibilities and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys 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 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.