Horsford 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. In particular, relating to fire safety, sharps safety, Control of Substance Hazardous to Health (COSHH), staff training, Legionella and the management of significant events.

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.

We saw that processes in place were ineffective for identifying and managing all risks, issues and performance, in particular regarding the management of fire safety, sharps safety, Legionella, significant events and COSHH. Improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

The practice must take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.

The practice must ensure that any recommendations in the Legionella risk assessment, considering the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance are implemented.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records.

There were some processes in place for identifying and managing most risks, investigating incidents and accidents, and for receiving and acting on safety alerts. However, improvements should be made to ensure learning resulted from significant events or accidents.

The practice had some 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.

Staff had clear responsibilities, and systems of accountability to support good governance.

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.

Feedback from patients was collected to which the practice responded.
 

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.