Mr. Nigel Monkman Also known as Nigel Monkmans 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 concerns related to:

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 and

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.

These concerns were in breach of Regulation 17 (Good governance) 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.

We were not assured that the responsible person understood their roles and responsibilities to support good governance and management. They were not always aware of the legal requirements or the compliance arrangements within the practice.

The information and evidence presented during the inspection was not clear or well documented.

There were ineffective processes for identifying and managing risks. We identified concerns regarding the management of risks associated with fire, Legionella, premises and equipment, Infection Prevention and Control (IPC), radiation safety, control of substances hazardous to health, sharps, medical emergencies, and safe staffing.

A general health and safety risk had not been carried out to identify workplace hazards, evaluate associated risks, and implement appropriate control measures to protect employees, visitors, and contractors from harm.

There were no systems in place to ensure recalls and rapid response reports relevant to the service issued by the Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and shared with staff.

The practice did not have an effective governance system, and we were not assured that policies and procedures were reviewed on a regular basis. While cover sheets in the policy folder indicated that policies were reviewed every 2 years, and included a signature to confirm this, reviews did not effectively identify that several policies, including the health and safety, and infection prevention and control policies, contained information not specific to the practice or referred to out-of-date guidance. The child protection policy did not include a clear process for staff to follow regarding the internal and external escalation of safeguarding concerns. Overall, we found that various policies were not suitable to guide staff in carrying out their day-to-day duties and did not include systems and processes reflective of the service.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. This practice did not carry out audits according to recognised guidance. There was a lack of understanding of what data should be included in audits and how reviewing processes could enable the practice to identify where quality and safety were being compromised. The practice could not demonstrate that audits of infection prevention and control, record keeping, disability access or antimicrobial prescribing were carried out regularly to support continuous improvement of care. The most recent infection prevention and control audit was dated 2014 and no record keeping, disability access, antimicrobial prescribing, or other audits were available for review.

The provider told us that concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. However, improvements should be made to ensure that the practice’s complaints procedure was displayed in the waiting area or at reception so that it was immediately accessible to patients.

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.

Staff were aware of the importance of protecting patients’ personal information. Paper records were stored securely and complied with General Data Protection Regulations.

The practice had taken steps to improve environmental sustainability, by saving energy and reducing waste where possible.

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.