Histon Dental Clinic

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 the maintenance of equipment, fire safety, medical emergency medicines, recruitment, continuing professional development for staff and the management of medicines.

We found that the registered person had ineffective systems for seeking and learning from patient feedback with a view to monitoring and improving the quality of the service.

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.

We saw that not all processes in place were effective for identifying and managing all risks, issues and performance, in particular regarding the management of equipment, fire, emergency medicines, recruitment, oversight of the continuing professional development of staff, medicines management and patient feedback. Improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

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.

There were effective processes for identifying and managing most risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

We were told that no complaints had been received by the practice, and so we could not review the complaints process. We saw that complaints information was on display for patients.

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

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.

Whilst there was a suggestions box in the waiting area, the practice did not actively gather feedback from patients, the public or external partners.

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.