The Elms 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 they have been put right by the provider. During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable 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. 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 evidence category 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.

During the inspection we found staff to be open to discussion and feedback. The practice staff and provider demonstrated a transparent and open culture in relation to people’s safety. Staff told us they had clear responsibilities, but roles and systems of accountability to support good governance and management could be improved. Staff also told us they felt clear definition of roles and the addition of a practice manager would be beneficial to the practice. Feedback from staff was obtained through meetings, surveys, and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Staff stated they felt respected and supported, but not always valued. They were proud to work in the practice. Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, the practice has a collection box for suggestions and comments, which patients are encouraged to share their feedback on. These are collected by the provider and feedback is shared at staff meetings. The provider confirmed that he takes suggestions on board and where practicable would act on these. The practice has positive online reviews and testimonials that they share on their website.

During the inspection, some information and evidence was not present and needed to be requested from staff. Some processes had not taken place, such as the registration with HSE for the use of ionising radiation. Following the inspection, we saw that this had been obtained. Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded in the day to day running of the practice. We saw that improvements were required to the processes in place to identify and manage risks in relation to fire management, hazardous substances, infection prevention and control, and staff recruitment and training. The practice had a governance system which included policies, protocols and procedures that were accessible to staff but were not always reviewed on a regular basis. For example, there was no policy for incident and accident reporting, consent, The Mental Capacity Act or Gillick competency and the protocol for fire management described by the provider was not reflected in any fire management plans, including the Health and Safety policy and fire risk assessment. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), however a DPIA had not been completed prior to installation. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts, but not a specific policy for this. The practice responded to concerns and complaints received appropriately. Staff discussed outcomes to share learning and improve the service. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits, but these were not always completed according to recognised guidance, such as the IPC audits not being completed 6 monthly. The practice should ensure that where appropriate, audits have documented learning points and resulting improvements can be demonstrated

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.