Langmans at Ely Place Dental Health Centre

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 and had taken into consideration appropriate guidance.

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 process to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in thedetailedfindings 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.

Systems and processes were not all embedded and we were told that a new compliance system was in the process of being introduced. The inspection highlighted some issues and omissions; however, the provider was aware of these and had an action plan in place to address some of the shortfalls identified.

Improvements were required in the oversight of staff training. The provider should have sufficient oversight to ensure that effective systems and processes were in place to monitor and manage staff training, mandatory learning, and continuing professional development (CPD).

Oversight of systems and processes required strengthening. For example, there was limited oversight regarding sedation checks. There was no evidence to demonstrate that pre-sedation checks had been completed or that patient consent was obtained prior to the sedation appointment.

Systems were in place for staff recruitment, however there was a lack of oversight to ensure that the required information was available on all occasions in line with regulations.

Medicines management systems required strengthening. The practice address was not recorded on medicine labels.

Oversight of maintenance and servicing of equipment required strengthening. Staff were not downloading data logger information for the autoclaves and did not have records to demonstrate that all the other relevant validation checks were completed.

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. Signed documents were stored electronically in patient records, this helped to improve data security.

There were processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits, although improvements were required to ensure they were completed in accordance with recognised guidance. The provider should take action to ensure audits of radiography, record keeping and antimicrobial prescribing were undertaken at regular intervals to improve the quality of the service. The existing audit process did not provide sufficient assurance that quality assurance requirements were being met by all clinicians.

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

We noted innovative approaches to providing person centred care. For example, one of the dental treatment rooms had a specialist tilting ramp. This allowed the patient to remain seated in their wheelchair while both the chair and wheelchair reclined together, making treatments more comfortable for the patient. Knee break chairs were available currently in 7 treatment rooms which aid patients with mobility difficulties to get in and out of the dental chair. The practice also had access to an intra-oral scanner which created a 3D digital model of the patient’s teeth without the need for traditional impressions.

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

Staff feedback was obtained through meetings and informal discussions. Staff said, “I feel involved with patient care with other dentists and if I need to raise anything or suggest anything I feel heard and supported. Nurses work well as a team and support me and reception are efficient in filling diaries,” and “I enjoy working here and especially the close team that I work with who make it enjoyable, we are very lucky to have some really lovely patients.”

A member of staff commented that, “there has been a lot of change recently to improve the practice and changes to management team to modernise and improve services.”

The practice had not completed staff appraisals recently. Staff comments regarding feedback were mixed with the majority stating that they did not receive regular feedback on their performance. The provider should develop systems to ensure an effective process is established for the ongoing assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals. We were told that appraisals had been scheduled for reception and dental nursing staff and discussions were being held with management regarding clinician appraisals.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. The practice had received a rating of 4.8 out of 5 from 486 online reviews.

The practice had taken steps to improve environmental sustainability. For example, staff turned off lights in rooms that were not being used, the use of the tablet for documentation signing by patients reduced the use of paper. The practice was trying to become paperless with the introduction of a new compliance system. Staff confirmed that they recycled wherever possible.

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.