Dental Arts - Harrogate Also known as Ace Denta Ltd

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. The provider had made insufficient improvements to address the shortfalls and had not responded in full to the regulatory breach we found at our inspection on 6 September 2024. In addition, new concerns surrounding recruitment processes were highlighted.

During our inspection of this key question, we found:

- A lack of systems or processes, and some ineffective systems that failed to enable the registered person to assess, monitor and improve the quality and safety of the services being provided.

- 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. This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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 found there was a continued lack of leadership and oversight to assess, monitor and improve the quality and safety of services provided, which led to the issues highlighted during the inspection. We have seen evidence of minimal understanding and lack of improvements since our last visit.

We were not assured that oversight and management of risks related to water systems was effective. Staff responsible for the ongoing monitoring of water systems could not demonstrate appropriate competence, training or knowledge to do so effectively. At previous inspections, we had signposted staff to the appropriate resources and support. An external risk assessment was completed on 12 September 2024. We saw there were multiple actions that had not been addressed including, “consider how the Responsible Person would demonstrate they have Legionella understanding and are competent.” There was also disagreement between staff over who was responsible for the oversight and monitoring of water systems.

Systems and process to maintain sufficient oversight of the X-ray equipment were still not working effectively. We saw outstanding actions from the X-ray machine’s 3-yearly performance test report dated July 2024 that had not been completed.

Systems and process to maintain sufficient oversight of staffs’ understanding of the medical emergency kit and their ability to respond appropriately to a medical emergency remained ineffective. We were not assured staff were sufficiently trained and familiar with the medical emergency kit. Staff could not demonstrate how to change the pads on the Automatic External Defibrillator and were unable to demonstrate an understanding of dose calculations for emergency medication.

Systems and processes had not been sufficiently implemented and there was limited improvement from the previous inspection. The provider showed a lack of understanding of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They were unable to demonstrate sufficient systems to identify where quality and safety were being compromised and to respond appropriately and without delay. Our follow-up inspection still highlighted issues and omissions, as well as additional concerns.

The governance system including policies, protocols and procedures remained ineffective and we were not assured that they were reviewed on a regular basis. There was no improvement to oversight and assurance processes to ensure all staff recruited had appropriate documentation, and there was a general lack of understanding of the importance of essential checks.

We looked at the recruitment policy which was based on a template from 2016. It did not include information listed in Schedule 3 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, such as proof of identity, and enhanced criminal record certificate. The provider had not updated the policy to reflect current legislation despite this being highlighted at our previous inspection.

Since our last inspection, a new member of staff had commenced employment, and this process highlighted new concerns around recruitment oversight. References had not been sought at the point of recruitment. A Disclosure and Barring Service (DBS) check had not been completed and was initiated one month after the start date. When queried, the provider advised us that they assumed the staff member’s training provider would have completed these checks. There was no risk assessment in place to mitigate the associated risks.

An induction had been carried out, but it did not include safeguarding. We were not provided with a logbook demonstrating the training the staff member had received, signed off by the designated supervisor, as required by the General Dental Council.

There was no evidence of vaccination history for one clinical staff member and no risk assessment in place, nor consideration of limiting their remit until full vaccination history was obtained. However, outstanding immunisation evidence for 2 other staff members had been added to their recruitment files.

Systems and processes for ensuring staff training was up-to-date and completed at required intervals were still ineffective. Training certificates had been requested at both previous inspections and a number were still missing. Evidence of fire safety training was missing for 2 staff members, one of which was the responsible person named on the external fire risk assessment. Radiography continuing professional development (CPD) was missing for one staff member. There was no system in place to identify if a staff member was up-to-date with their required training or if training had expired.

There was a lack of improvement in systems to assess, monitor and improve the quality and safety of the services being provided. Infection prevention and control (IPC) audits and record-keeping audits that were highlighted as missing at the previous inspection had now been completed. However, the record-keeping audit had only been partially completed. Half of the sample size recommended in the template had been used and the summary page was left blank, including results, action plans and shared learning. The IPC audit also did not contain an action plan or shared learning. The radiography audit was incomplete.

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.