Pinner Road 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

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of 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. In particular, relating to fire safety, recruitment procedures, equipment maintenance, governance and management.

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.

Improvements were required to the practice’s governance system, ensuring policies were reflective of practice procedures, and were consistently adhered to. We found that recruitment procedures were not in line with practice policies and were not in line with relevant legislation.

Systems and processes were not embedded, particularly relating to consistent servicing of equipment.

The management of risks required improvement. This included fire safety, equipment safety, Legionella, and sharps safety.

The practice had some systems and processes for learning, quality assurance and continuous improvement. However, audits were not consistently completed and did not always have action plans or evidence of shared learning. There was no current or previous radiography audit available for review. The disability access audit highlighted the same actions points in consecutive years indicating that improvements had not been reviewed or implemented. In addition, the antimicrobial audit was completed at inconsistent intervals.

The provider responded positively and proactively to our feedback and has recently employed a practice manager to strengthen oversight and management of the practice.

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

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.

Staff feedback was obtained through meetings, surveys, 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. For example, taking into account individual preferences when scheduling staff lunch breaks.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, changing the colour contrast on appointment reminders so staff could read them more easily.

The practice had taken steps to improve environmental sustainability. For example, recycling, encouraging public transport for staff commuting and turning equipment off when not in use.

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.