ADVANCE DENTAL CARE

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 foundthe 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 systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Improvements could be made to ensure that audits had documented learning points, so that resulting improvements could be demonstrated. Staff had clear responsibilities, and systems of accountability to support good governance. There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

Staff feedback was obtained through 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 was collected to which the practice responded. Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

The practice had taken steps to improve environmental sustainability. For example, by using light-emitting diode (LED) lightbulbs and by moving to digital records.

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. Following feedback from the inspection team, the practice ensured that the room storing paper dental care records was secured, to ensure compliance with General Data Protection Regulations.

Systems and processes were not fully embedded. The practice's risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities required improvement. In particular, the risks associated with fire safety, infection prevention and control, management of medical emergency equipment and medicines, Legionella, Control of Substances Hazardous to Health (COSHH), lone working and sharps safety. In addition, improvements were required to recruitment processes, to ensure they complied with legislation.

Where the assessment identified areas which required improvement, the practice took some immediate action. We will be following up on our concerns to ensure the provider had made the required improvements, and that good governance and leadership are sustained in the longer term.

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.