Oakthorpe Dental

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.

The registered person did not have effective systems to maintain records as are necessary to be kept in relation to persons employed. This included information relating to the requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 ineffective systems and processes for learning, quality assurance and continuous improvement. Although audits were undertaken, these were not completed according to recognised guidance. Improvements are required to ensure audits of radiography, infection prevention and control, legionella and antimicrobial prescribing are undertaken at regular intervals to maintain or improve the quality of the service. The practice should ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be clearly demonstrated.

The practice had a governance system in place which included policies and procedures that were accessible to staff and generally reviewed on a regular basis. However, the system required improvement as we did not see evidence of specific policies relating to Mental Capacity Act, Gillick competence and Duty of Candour. In addition, improvements were needed to ensure that records relating to staff employment were maintained in accordance with legislative requirements and current guidance.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records. However, the storage of completed accident records did not comply with General Data Protection Regulation (GDPR) requirements.

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 and Legionella.

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

Staff feedback was obtained through informal discussions. They were encouraged to offer suggestions for improvements to the service.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

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.