Neem Dental Clinic

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 recruitment procedures, fire safety, electrical equipment maintenance, medical emergencies management and governance and oversight.

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 equipment maintenance and oversight of staff training.

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

There were ineffective processes for receiving and acting on safety alerts. The practice principal was not aware of any relevant Patient Safety Alerts, recalls and Rapid Response Reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).

The practice had some systems and processes for learning, quality assurance and continuous improvement. However, radiography, antimicrobial prescribing and record-keeping audits were only completed for the principal dentist, rather than for all clinicians. The radiography audit sample size was not in accordance with recognised guidance.

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 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, a television screen was put up in the surgery so that clinicians could show patients their clinical photos and x-ray images.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, recycling and turning lights and 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.