Norwich Street Dental Surgery

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. In particular relating to a lack of assessment of all risks including health and safety, lone working and sharps. Also relating to safeguarding, radiation safety, audits of infection prevention and control, medicines management, disability access audits, storage of patient records, and a lack of policies.

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 inspection highlighted some issues and omissions.

We saw that there were limited processes in place for identifying and managing all risks, issues and performance. Significant improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

The practice did not have a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. Multiple policies were not present, including consent, speaking up, Duty of Candour, recruitment and safeguarding. We saw that some policies, for example the Equality Diversity and Inclusion policy, were dated 2010 and had not been reviewed since.

We saw that there was no business continuity plan, and therefore no process in place to help identify and plan for anticipated risks to the delivery of the service.

Staff were not fully aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records. However, paper records were not stored securely and were accessible to anyone in the practice.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. We saw that audits were not always undertaken according to recognised guidance.

We saw that no complaints information was on display for patients. The practice told us they had not received any complaints.

Staff feedback was obtained through informal discussions.

The practice gathered feedback from patients through the use of a survey.

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.