The Fenton Dental Studio

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. This resulted in a breach of Regulation 17 (Good governance) 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. We found that the provider had the values and commitment to deliver high quality sustainable services. However, the ineffective assessment and mitigation of risk and lack of oversight of training impacted the day to day management of the service. Staff told us how they collected and responded to feedback from patients. Improvements could be made to ensure that analysis of feedback included a reference to sample size, timescale of survey, questions asked, and a summary of trends identified for meaningful continuous improvement. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Staff stated they felt respected, supported and valued. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. 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. One staff member told us “I feel not only me but the whole team are comfortable enough with each other to communicate openly and honestly regarding our job roles and shared duties.” Staff told us how they collected and responded to feedback from patients, the public and external partners. The practice had taken steps to improve environmental sustainability. They segregated waste and used digital communications tools where possible.

The information and evidence presented during the assessment was not always clear and well documented. 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, these were not always reflective of the arrangements within the practice. The practice ‘Fire Safety Action Plan’ was not suitable to effectively support the management of fire safety at the practice. There were ineffective processes for identifying and managing risks and performance. We identified concerns around the management of risks associated with fire, COSHH, storage of waste and monitoring of training. 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). The practice had systems to review and investigate incidents and accidents, and 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 practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

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.