Brownhills 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 assessment of this key question, we found a lack of systems and 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 and 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 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.

There was a lack of sufficient governance and oversight to identify and manage various risks, including risks associated with dental radiography, medical emergencies, recruitment, training oversight and fire safety management.

The practice had a governance system that included policies and procedures, which were accessible to staff, however not all of these were reviewed on a regular basis.

Although systems and processes were not embedded, and the inspection highlighted issues and omissions, areas requiring improvement were acted on immediately, demonstrating the providers commitment to offer safe and well-led services to their patients.

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 investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice systems and processes for learning, quality assurance and continuous improvement were ineffective. Audits were not being carried out according to recognised guidance, we did not see recommended antimicrobial and mandatory radiography audits for all clinicians and the practice did not carry out recommended clinical record audits.Infection prevention and control audits were not being completed every 6 months and did not reflect our findings on the day of the inspection.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We did not see evidence staff had clear responsibilities, and systems of accountability to support good governance. The provider implemented an action plan to address this immediately following the inspection.

Staff feedback was obtained through meetings, newly introduced appraisals, 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.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

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.