Catherine Street 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 regulation. We will be following up on our concerns to ensure the provider has 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.

In particular, we found improvement was needed in the management of training, control of substances hazardous to health, emergency medicines and equipment, infection prevention and control and fire safety.

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 provider’s oversight of regulatory requirements required improvement.

Systems and processes were not embedded among staff which highlighted a number of issues which included, training, control of substances hazardous to health, emergency medicines and equipment, infection prevention and control and fire safety management.

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

Improvement was needed to ensure the practice had 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.

The storage of completed staff recruitment, accident and complaint records did not comply with General Data Protection Regulation requirements.

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.

The practice gathered feedback from patients and responded accordingly. For example, a water dispenser was installed in the patient waiting area.

Staff told us how they went over and above to support patients by delivering medicines and an occasion when they took patient home after treatment.

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.