Charlbury 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 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 and did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed.

This resulted in a breach of Regulation 17, Good governance.

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 practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Although audits were undertaken, these were not completed according to recognised guidance by ensuring that audits have documented learning points, and the resulting improvements can be demonstrated. Areas requiring improvement were acted on immediately.

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.

Relevant policies and protocols were not in place for the use of a surveillance system. There was no documentation in place for the system used to view visual images, including a policy, a privacy notice, or Data Protection Impact Assessment (DPIA).

There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts, but the processes for identifying and managing risks required improvements. In particular, the risks associated with fire safety, medical emergencies and Infection Prevention and Control.

The provider had not effectively identified and managed risks relating to patients' privacy and dignity. Visibility into a treatment room was possible through both internal and external windows. While a sign had been displayed on the external window requesting that patient privacy be respected, this did not fully address the risk of patients being observed while receiving treatment.

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

We noted innovative approaches to delivering person-centred care. For example, the practice used video consultations to assess patients and discuss their needs, enabling clinicians to determine whether a face-to-face appointment was required and supporting timely access to care.

Staff feedback was obtained through meetings 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 used this information to make improvements. For example, larger fire exit signs had been installed to improve visibility, and a wheelchair had been purchased to enhance accessibility for patients with mobility needs.

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.