Mr Osman Mohammed Also known as Manningham Lane 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.

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 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, which were accessible to staff and were reviewed on a regular basis. However, these were generic and not personalised to the practice to support the provider and staff to ensure these were followed effectively.

Staff did not have clear responsibilities, and systems of accountability to support good governance.

There was a lack of oversight to identify and manage risks in relation to staff recruitment, induction and training, assurance of medical emergency procedures, hazardous substances and inconsistencies in infection prevention and control processes.

There were systems for receiving safety alerts, but no evidence of these being reviewed and actioned as appropriate.

The provider and staff were open to discussion and feedback. Where the inspection highlighted issues or omissions, staff took immediate action to address these. However, several issues of a similar nature had also been highlighted and discussed at previous inspections. Whilst improvements had been made at the time, these had not been embedded and sustained to ensure ongoing compliance.

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.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included investigating incidents and accidents and undertaking audits according to recognised guidance.However, the infection prevention and control audits did not identify areas of improvement highlighted by the inspection.

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

Staff feedback was obtained through meetings and 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.