HA1 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 and 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. In particular, relating to fire safety, recruitment procedures, medical emergencies, equipment and premises maintenance, oversight of continuing professional development, and governance and management.

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. However, oversight of some areas of governance required improvement. Issues were identified relating to fire safety management, recruitment procedures, and oversight of staff training. The provider has been responsive, and many of the issues highlighted on inspection have been acted on.

We saw an accident logbook; however entries did not include any follow up information or shared learning for staff.

Concerns and complaints were not always responded to appropriately. We discussed this with the provider and were assured this would be addressed.

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 in place for the use of closed-circuit television (CCTV).

There were effective processes receiving and acting on safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, audits were not always completed at the frequency required by recognised guidance.

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. For example, CCTV had been installed to enhance staff safety and provide reassurance. A digital X-Ray system was introduced to improve safety, comfort and diagnostic accuracy.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, a card payment machine was introduced for patient payments, and courtesy calls prior to appointments were implemented to remind patients of their appointments.

The practice had taken steps to improve environmental sustainability. For example, being mindful or energy and water usage, and switching lights off when not in the room.

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.