Abbeydale Dental Care Centre-Sheffield

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: Systems and processes to assess, monitor and improve the quality and safety of the services being provided were not effective. 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.

We found staff to be open to discussion and feedback. Staff told us they had clear responsibilities, roles and systems of accountability to support governance and management. Feedback from staff was obtained through meetings 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, supported and valued. They were proud to work in the practice. We saw the practice had processes to support and develop staff with additional roles and responsibilities. The manager was open about systems not being established to review and ensure staff were up to date with their mandatory training and their continuing professional development. New systems were in the process of being introduced but these were not yet embedded. We were sent evidence after the inspection that clinical staff completed appropriate training in safeguarding, infection prevention and control, fire safety and sepsis awareness. However, there were still some gaps in training to be addressed. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. However, the recruitment policy was not followed. The practice had taken steps to improve environmental sustainability.

Systems and processes were not embedded. Where the assessment identified areas which required improvement the manager showed a commitment to ensuring these were acted on to prevent reoccurrence. The information and evidence presented during the assessment was not always clear and well documented. Particularly for recruitment processes. The practice had information governance arrangements and 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 (GDPR). We saw there were ineffective processes for identifying and managing risks, issues and performance. Particularly for the management of radiography and Legionella. The practice had inconsistent systems to review and investigate incidents and accidents. Staff were encouraged to report any incidents and we saw some incidents were well documented and the resulting learning had been shared with staff. However, we reviewed a recent sharps injury. A process wasn’t in place to ensure appropriate timely advice and follow up could be evidenced. There was a process for receiving and acting on safety alerts. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service. The systems and processes for learning, quality assurance and continuous improvement should be reviewed. Audits of radiography were not undertaken at the appropriate intervals to improve the quality of the service. These were completed and sent after the assessment. Audits did not have documented learning points and improvements could not be demonstrated. In particular, audits of antimicrobial use did not highlight that documented justifications to prescribe were not in line with nationally accepted guidance from the College of General Dentistry. We signposted them to resources to support this process.

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.