Poldent Dental Care

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.

At the time of the inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

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. We also found ineffective 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.

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.

The provider did not have effective systems and processes to assess, monitor and improve the quality and safety of the service. Their systems did not enable the provider to identify where quality and safety were being compromised and to respond appropriately and without delay.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, these were not working effectively. Recruitment policies had not been followed and safeguarding concerns had not been acted on.

Processes were not in place to identify and manage risks in relation to fire safety, recruitment, ensuring the servicing of equipment at appropriate intervals and the oversight of infection prevention and control processes.

The provider had not implemented systems for reviewing and investigating when things went wrong. In particular, processes to document and investigate incidents and accidents were not followed. We were shown an events log where incidents had been entered but no detail had been added to ensure appropriate action was taken and learning occurred. Additional issues were highlighted during the inspection which the provider should have recognised as significant events from which systems could have been reviewed and changes implemented to prevent reoccurrence.

The practice had processes for receiving and acting on safety alerts, quality assurance and continuous improvement. Radiographic quality audits were carried out according to recognised guidance.However, these did not include conclusions.

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.

Staff feedback was obtained through meetings and informal discussions.

Feedback from patients, the public and external partners was collected to which the practice responded.

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.