The Dental Team

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 them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the ineffectiveness of the 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. They did not have effective systems to ensure dental records were completed appropriately. In addition, they had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office. 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 assessment 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.

At the time of our inspection the practice was reliant on temporary agency staff and had a number of newly recruited staff members. This impacted on the day-to-day running of the practice. We found staff to be open to discussion and feedback and were honest about the current challenges they faced. We saw the practice had processes to develop staff with additional roles and responsibilities. However, we noted more structured support and training may be required to ensure all staff members were able to carry out their duties appropriately. The practice did not have the relevant policies and protocols were in place for the use of closed-circuit television (CCTV). Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations (GDPR). Patients had access to digital equipment to assist with the completion of forms. In addition, the practice used an online digital platform to assist with the ongoing management of the practice.

The oversight of the practice did not ensure the systems and processes were embedded in the day-to-day running of the practice. The practice had ineffective systems relating to fire management, equipment and premises, hazardous substances, infection prevention and control, waste management, record keeping, staff recruitment and training and radiography. The practice had systems to review and investigate incidents and accidents, which included an accident book and the use of an online reporting system. However, we could not be assured all staff knew the location of the accident book. The systems to report accidents and incidents were not consistently followed and some reflections and learnings recorded were not relevant to the incident and would not have prevented re-occurrence. The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. Audits of radiography and IPC were not undertaken according to recognised guidance. The practice should take action to ensure audits of patient care records are undertaken at regular intervals to improve the quality of the service. As part of the assessment, we looked at 18 dental care records. Of the records we saw, 5 did not contain any information relating to the appointment, such as individual patient’s risk assessments, periodontal diagnosis, options given or consent and did not meet the minimum recommended requirements. The provider did not have protocols in place to ensure these minimum standards were consistently met. The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information.

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.