Kilburn Corner Dental

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 improve the quality and safety of the services being provided.

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.

The registered person was failing to maintain securely such records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activities.

The registered person was failing to maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.

This resulted in a breach of Regulation 17, Good governance 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.

We were not assured that the responsible person understood their roles and responsibilities to support good governance and management. They were not always aware of the legal requirements or the compliance arrangements within the practice. We asked about, and the responsible person was not aware of the high and medium-risk recommendations identified within the most recent fire and Legionella risk assessments. This meant that they could not effectively prioritise, monitor, or implement corrective actions.

The information and evidence presented during the inspection was not always clear or well documented.

There were ineffective processes for identifying and managing risks. We identified concerns regarding the management of risks associated with fire, Legionella, premises and equipment, and safe staffing.

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 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 ensure that record-keeping and radiography audits clearly identified areas requiring improvement and included appropriate action plans to support and monitor improvements in these areas,

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

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. Improvements could be made to ensure the practice had structured meetings in place to routinely cover core topics, including medical emergency scenarios, safeguarding, fire safety, and updates to policies and risk assessments.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. Improvements could be made to ensure the practice has a structured process for obtaining patient feedback from both NHS and private patients, with feedback regularly reviewed and analysed to identify trends, themes and opportunities for service improvement.

The practice had taken steps to improve environmental sustainability by saving energy and reducing waste 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.