Dentexcel - 8 Angel Court

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 a lack of 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.

The registered person did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed. This included information relating to the requirements under Regulations 4 to 7 and/or Regulation 19 of this part (part 3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Governance systems were not effective in ensuring oversight of staff training, as accurate and complete records relating to persons employed were not maintained as required.

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. However, these systems and processes were not fully embedded. Where the inspection highlighted issues, areas requiring improvement were acted on immediately. We will be following up on our concerns to ensure the provider has made the required improvements, and that good governance and leadership are sustained in the longer term.

Improvements were required to the practice's risk management arrangements to ensure that risks arising from the provision of regulated activities were effectively identified, assessed, monitored, and mitigated. In particular, the risks associated with fire safety and the management of medical emergency equipment and medicines. In addition, improvements were required to ensure the documentation relating to staff training and evidence of immunity to Hepatitis B are readily available.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records and complied with General Data Protection Regulations. Improvements were required to the storage of patient paper records, as these were stored within unlocked filing cabinets.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.However, improvements were required to these audits to ensure they effectively identified areas requiring improvement and had documented action plans to help drive these improvements.

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

The practice had not received a formal complaint in the year preceding our inspection. The practice had systems and processes in place to ensure that concerns and complaints would be responded to appropriately, with outcomes 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 and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, by turning off equipment when not in use and recycling 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.