Bradford Urgent 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:

Systems were not effective in identifying, monitoring, or mitigating risks to the health, safety, and welfare of people using the service and others who may be affected.

Systems to maintain essential management records were ineffective, particularly for risk assessments relating to recruitment checks.

Systems to ensure accurate, complete, and up-to-date records were securely maintained for each person using the service were ineffective.

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 oversight of the practice did not ensure that systems and processes were fully embedded in the day-to-day running of the practice.

The practice had ineffective systems for the ongoing assessment and management of risks, including fire safety, IPC equipment testing and the management of Legionella, as well as ineffective systems related to record keeping and staff recruitment.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

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.

There were processes in place for identifying and managing incidents and accidents, and for 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.

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

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 had taken steps to improve environmental sustainability. For example, recycling where possible and turning of electrical appliances when not in use.

While the practice had systems and processes for learning, quality assurance, and continuous improvement, including audits based on recognised guidance, improvements should be made to auditing protocols to ensure they include reflective outcomes and appropriate action plans to drive areas of improvement identified during inspection.

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.