Night and Day Emergency Dentist

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 assessment of this key question, we found:

A lack of systems or processes that enabled the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. Where processes were in place, they were not always working effectively.

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 provider did not always operate effective systems and processes to ensure they assessed and monitored their service against and in compliance with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a lack of leadership and oversight at the practice. Systems and processes were not embedded, and the inspection highlighted some significant issues and omissions. The provider had taken immediate action for some of the issues identified, but there were still significant issues to be addressed.

There were ineffective processes for identifying, monitoring and mitigating all risks which arise from the carrying on of the regulated activity. In particular, the management of risks related to Legionella, infection prevention and control, sharps safety, clinical waste, and staff training.

Oversight of safeguarding procedures was ineffective and supporting governance required improvement. In addition, there was a lack of assurance that staff had completed required safeguarding training at a level and frequency appropriate to their role.

The safeguarding policy we saw on the day did not reflect our findings, was not dated and contained information for another dental practice, including the practice manager details. The safeguarding posters and flow charts displayed to support staff with appropriate and timely escalation had not been updated for several years and did not include contact details for local safeguarding teams.

It was apparent the safeguarding policy available not embedded as the two members of staff we spoke with on the day of inspection were unaware of their responsibilities for safeguarding vulnerable adults and children and did not know who to contact if they had a safeguarding concern. The provider submitted an updated safeguarding policy in the days after the inspection.

The governance systems were not effective and not specific to the practice. Required policies and procedures were missing key information and on the day of inspection were unavailable for all staff to access. For example, the infection prevention and control policy, lone worker policy and whistleblowing policy all contained information relating to another practice and hazardous waste consignment notes were not available on the inspection day. There was limited evidence that the practice’s policies, protocols and procedures had been reviewed on a regular basis and some were not reflective of current guidance.

The practice did not have systems and processes in place for learning, continuous improvement and innovation. Audits that had been completed were not working effectively in that they had not provided sufficient scrutiny of local practice to enable the provider to identify where quality and/or safety were being compromised and to respond appropriately without delay.

The provider had not completed a Data Protection Impact Assessment to assess the purpose, necessity, and risks prior to installation of Close Circuit Television (CCTV). In addition, there were no signs at the practice to inform staff, service users, or visitors that CCTV was in operation. The CCTV was also streamed to a live feed which was visible within a surgery.

However, staff we spoke to were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely.

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.