The Mall 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.

The registered person did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed. This included information relating to the requirements under Regulation 19 of this part (part 3) of 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 a governance system that included policies and procedures, which were accessible to staff, but which required improvement. For example, the practice did not have effective systems for ensuring policies were reviewed and updated regularly, or for monitoring staff training and development. In addition, improvements were required to ensure that they stored records relating to people employed, in compliance with legislation and taking into account current guidance. Areas requiring improvement were acted on immediately but were not yet embedded at the time of this inspection.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Although audits were undertaken, these were not always completed according to recognised guidance. Action is needed to ensure audits of infection prevention and control are undertaken at regular intervals to maintain or improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated.

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. However, the system for monitoring complaints, and for ensuring complaints information and guidance were accessible, required improvement.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and overall, paper records were stored securely and complied with General Data Protection Regulations.

Staff had clear responsibilities, and systems of accountability to support good governance.

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 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.