• Dentist
  • Dentist

Kimbolton Dental Practice

52 High Street, Kimbolton, Huntingdon, Cambridgeshire, PE28 0HA (01480) 860618

Provided and run by:
Dr Marco Riccardo Zaina

Important: The provider of this service changed. See old profile

Report from 24 June 2024 assessment

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Well-led

Not all regulations met

2 April 2025

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 has made the required improvements.

During our assessment of this key question, we found that the registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person 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 regarding fire safety, electrical safety, Control of Substances Hazardous to Health (COSHH) regulations, sharps safety, recruitment and infection prevention and control (IPC).

This resulted in a 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 report findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

Shared direction and culture

Regulations met

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

Capable, compassionate and inclusive leaders

Regulations met

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

Freedom to speak up

Regulations met

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

Workforce equality, diversity and inclusion

Regulations met

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Governance, management and sustainability

Not all regulations met

Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management.

Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

Staff stated they felt respected, supported and valued. They were proud to work in the practice.

Staff told us how they collected and responded to feedback from patients.

We saw the processes in place were not effective for identifying and managing all risks, issues and performance, in particular regarding the management of fire safety, electrical safety, sharps safety, IPC, recruitment and the management of COSHH. Improvements were needed to the oversight of the practice to ensure that it was consistently well-led for patients and staff.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. However, during the inspection, we saw repeated breaches of confidentiality as a staff member discussed and updated patients’ medical history in the waiting room in front of other waiting patients. Following our feedback, the practice said they would now complete this in the surgery.

Staff password protected patients’ electronic care records.

The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts.

The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

The practice had systems and processes for learning, quality assurance and continuous improvement. Audits were being carried out, yet multiple audits were not reflective of practice procedures or current guidance, and hence were not suitable to drive improvement.

Partnerships and communities

Regulations met

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

Learning, improvement and innovation

Regulations met

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.