Galley Hill Dental Surgery

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 mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, regarding fire safety, electrical safety, servicing and maintenance of equipment, management of medical emergencies and Legionella management.

The registered person did nothave effective systems to maintain records as are necessary to be kept in relation to persons employed. In particular, regarding oversight of training and recruitment.

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.

We found staff to be open to discussion and feedback. The provider was receptive to feedback on areas where improvement was needed and provided evidence to show where immediate action had been taken to address some of the concerns identified. This demonstrated commitment of the provider to making improvements for both staff and patients. However, these systems and processes needed to be embedded.

The practice staff demonstrated a transparent and open culture in relation to people’s safety. However, improved oversight was needed to ensure there was an understanding of the essential requirements and regulations.

We found the provider had the values and commitment to deliver high quality sustainable services. However, the lack of oversight of training, ineffective risk management and governance shortfalls all impacted the day-to-day management of the service.

Policies and procedures were reviewed and made available to staff, although the information and evidence presented during the inspection was not always clear, available and well documented.

Staff were aware of the importance of protecting patients’ personal information and password protected patients’ electronic care records. An electronic device was used by patients to sign documents as part of the patient record, this helped to improve data security. Improvements could be made to demonstrate General Data Protection Regulation (GDPR) compliance by the completion of the Data Security and Protection audit toolkit.

There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with medical emergencies, management of used sharps, infection prevention and control, COSHH, radiation protection, lone working, recruitment and training monitoring.

The practice signed up to receive safety alerts on the day of the inspection. Processes to review and investigate significant events, incidents and accidents were limited.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Audits for radiography, record keeping, antimicrobial prescribing did not include all clinicians and were not used to identify areas for improvement. There were no systems in place for monitoring training to ensure that all staff received training appropriate to their role at required frequencies.

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

Staff feedback was obtained through informal discussions and a digital chat. Staff said they were encouraged to offer suggestions for improvements to the service.

The practice gathered feedback from patients, the public and external partners though surveys and digital reviews.

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.