Hall Street Dental Care

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. We also found ineffective 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.

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.

Improvements were required to some of the practice’s systems and processes to improve management oversight. The on-site inspection highlighted some significant issues and omissions. The practice acted immediately to reduce the risk of some of these issues.

Improvements were required to the governance systems to ensure policies and procedures were regularly reviewed and easily accessible to staff.

We noted improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with sharps safety, stock control, premises and equipment, lone working, fire safety and medical emergencies.

There were processes for investigating incidents and accidents, and for receiving and acting on safety alerts. However, we were unable to check if these were effective as there had been no accidents or incidents recorded since 2013.

The practice had some systems and processes for learning, quality assurance and continuous improvement. The practice carried out radiography audits in line with recognised guidance. However, we noted improvements were required to ensure infection prevention and control audits were carried out in line with recognised guidance and were reflective of practice protocols.

We were unable to check concerns and complaints were responded to appropriately as these documents were not available on the day of inspection. Improvements were required to ensure a patients complaints procedure with escalation options is available for patients.

Staff feedback was obtained through meetings and informal discussions.

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 where possible.

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 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.