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 carein accordance withthe relevant regulations.We will be following up on our concerns to ensure the providerhad made the required improvements.

During ourinspectionof this key question, we found:

The registered person hadineffectivesystems or processes to enable themto assess,monitorand mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

Thisresulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in thedetailedfindings 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’s policies, procedures and risk assessments were not always regularly reviewed and readily available for all staff that work in the practice, as well as any other external partners or bodies that may request them. Some systems and processes underpinning these policies and procedures were not fully embedded to ensure good governance and effective management of risk.

The provider was open to discussion and feedback to improve the practice. They were open and honest about systems, policies and documents that were either missing or misplaced when we requested to see them. They demonstrated a very caring attitude for patients and had acted with good intentions to obtain staff to ensure that patients could continue to receive care but did not have full oversight of the risks relating to this.

Improvements were required to the systems and processes for managing the risks associated with the carrying on of the regulated activities. The inspection highlighted shortfalls with carrying out and recording required checks on fire safety equipment, there were no lone worker risk assessments in place, including to protect staff and patients entering people’s homes alone when providing domiciliary dental services, and not all required recruitment documents had been obtained in line with policy for new staff members.

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.

There were not always effective processes for identifying and managing risks and for receiving and acting on safety alerts. However, there were processes in place to investigate incidents and accidents.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

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

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 also used paper cups instead of plastic. The practice also switched lights and equipment off when not in use to conserve energy.

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.