ESTE DENT LIMITED

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 that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also 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.

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 did not have an effective governance system. Policies were brief and did not reflect accurately practice procedures. We did not see evidence that policies were reviewed on a regular basis as most policies were dated after we announced our inspection. We also did not see evidence that staff had read and reviewed polices.

Systems and processes were not embedded or operating effectively, the inspection highlighted significant issues and omissions across a range of areas. Whilst some areas requiring improvement were acted on immediately, further work was required to implement and embed changes across the practice.

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.

There were ineffective processes for receiving and acting on safety alerts. The practice principal was not aware not aware of any relevant Patient Safety Alerts, recalls and Rapid Response Reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. Audits were not undertaken in accordance with recognised guidance.We saw audits for each of the required topics; however, the templates were not fit for purpose and did not highlight the issues we observed during the inspection.
The radiography audit reviewed 7 radiographs rather than the recommended 100. It used an old grading system and did not include sufficient information for an effective audit.
Infection prevention and control and radiography audits were completed annually rather than the required 6-monthly interval. The antimicrobial audit reviewed was current, however, there was no previous one available for review, therefore we were not assured that they were routinely completed. Improvements were required to audits to ensure they effectively identified areas requiring improvement and had documented action plans to help drive these changes.

Staff were aware of the importance of protecting patients’ personal information. However, the provider was not registered with or have an awareness of the Information Commissioner’s Office (ICO). Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

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. For example, the layout of the surgery was reorganised to optimise access to the patient, improving the efficiency and ergonomics of treatment delivery.

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

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.