Kirkholt Dental 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. 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.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Systems and processes did not always enable effective oversight of the service provided and the inspection highlighted areas requiring improvement. Staff were open to discussion and feedback, and some of the areas requiring improvement were acted on immediately with evidence sent after the inspection.

The processes for identifying and managing risks were not always working effectively. The inspection highlighted shortfalls in the governance and oversight of risk in relation to medical emergency arrangements, fire safety, recruitment procedures and radiation protection. The provider took some immediate action by ordering missing items and implementing new checklists. We will follow-up to ensure the new processes are effective and embedded.

Processes for investigating incidents and accidents, and for receiving and acting on safety alerts should be reviewed. We reviewed the report for a recent sharps incident had not been documented as followed up appropriately, or investigated for learning to prevent reoccurrence. Staff highlighted challenges with the processes to obtain timely advice. We highlighted the documentation of these incidents should be improved.

We were not assured there was a current system to receive patient safety alerts as the most recent one logged was from 2023. After the inspection the practice took action to address this.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Some of these required strengthening, in particular systems of oversight for staff training to ensure mandatory training is completed at required intervals and at the required level.

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.

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

Staff feedback was obtained through meetings, surveys, a secure phone messaging application 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.

Feedback from patients, the public and external partners was collected to which the practice responded.

The practice had taken steps to improve environmental sustainability. For example, digital systems were used to reduce the use of paper.

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.