Worthing 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.

At the time of the inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

During our inspection of this key question, we found theregistered 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.

the registered person had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office.

This resulted in a breach of Regulation 17 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.

Leadership at the practice was ineffective as there was a lack of oversight of the day-to-day management of the service. There was no registered manager in post and an offsite practice manager who worked remotely.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. The provider had a compliance system to support staff with the governance arrangements, but we found this was not used effectively. We saw audits had been completed but actions had not always been identified or addressed. IPC audits had not detected the issues found during the inspection. The disability access audit was not reflective of the practice and had not highlighted where actions were required. There were gaps in staff training which had not been identified. Overall, the provider had not identified the gaps in their quality monitoring processes.

Staff feedback was obtained through 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. However, some feedback comments told us that staff meetings were not held regularly and that communication with leaders was limited to emails and social media messages.

Relevant policies and protocols were not in place for the use of closed-circuit television (CCTV).

The provider had completed a Data Protection Impact Assessment (DPIA) but this did not include information about the use of CCTV or the necessity and assessment of risks associated with its use.

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

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning. Improvements were needed to ensure that the complaints procedure was updated with the named lead person for complaints and that it was readily accessible to patients in the practice.

The practice had information governance arrangements and 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.

The processes for identifying and managing risks, were not always effective. In particular, the risks associated with fire, electrical safety, infection prevention and control and staff recruitment.

Policies, protocols and procedures were in place, but these were difficult to find, not easily accessible for all staff and were not regularly reviewed.

Where the inspection identified areas which required improvement, the provider submitted some information following the inspection. This provided us with some assurance that the provider was implementing improvements. However, evidence is required to demonstrate that any improvements are embedded into the day to day running of the practice.

Feedback from patients, the public and external partners was collected and analysed, although it was not always clear the practice had responded to feedback. For example, we saw that no action was taken in response to findings from a patient feedback audit in April 2024.

Staff feedback was obtained through 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. However, some feedback comments told us that staff meetings were not held regularly and that communication with leaders was limited to emails and social media messages.

Relevant policies and protocols were not in place for the use of closed-circuit television (CCTV).

The provider had completed a Data Protection Impact Assessment (DPIA) but this did not include information about the use of CCTV or the necessity and assessment of risks associated with its use.

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

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning. Improvements were needed to ensure that the complaints procedure was updated with the named lead person for complaints and that it was readily accessible to patients in the practice.

The practice had information governance arrangements and 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.

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.