Overton Dental Practice

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 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.

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. However, it was not clear whether policies had been reviewed regularly, or which versions of the policies were being followed and the overall governance systems and processes required improvement. In particular, the practice should take steps to improve the risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities and implement procedures to ensure staff are up to date with their mandatory training and their continuing professional development. Following the inspection, we received confirmation of the provider’s plans to improve their systems, including considering implementing a compliance suite. Areas requiring improvement were acted on immediately, where possible, but are not yet embedded.

There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts, but the processes for identifying and managing risks required improvements. In particular, the risks associated with fire safety and Legionella.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV). However, improvements could be made to ensure these were wholly reflective of the practice.

The practice had systems and processes for learning, quality assurance and continuous improvement. Although audits were undertaken, these were not completed according to recognised guidance. Action is needed to ensure audits of radiography, infection prevention and control, and antimicrobial prescribing are undertaken at regular intervals to maintain or improve the quality of the service. The practice should ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be clearly demonstrated.

The system for recording and monitoring of complaints, required improvement. Staff told us concerns and complaints were responded to appropriately, and dealt with immediately face to face, but we did not see any documentary records of complaints or their outcomes.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and records were stored securely and complied with General Data Protection Regulations.

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.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, the seating in the waiting area was changed in response to patient feedback.

The practice had taken steps to improve environmental sustainability. For example, they actively recycle, have installed motion activated sensor lights and a bike rack to encourage cycling.

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.