Wimpole Dental Office

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. Where the assessment highlighted issues, the practice took some action to address these concerns immediately.

We found that the provider had the values and commitment to deliver high quality sustainable services. However, the ineffective management of risks, lack of oversight and processes for continuous improvement impacted the day-to-day management of the service.

Staff told us leaders in the practice were approachable, they felt involved in the future development of the practice. Staff felt respected, valued and supported and they were confident that if they raised concerns, these would be listened to and addressed.

Feedback from staff was obtained through meetings, 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 told us how they collected online feedback from patients.

Improvements could be made to ensure the practice proactively sought feedback from patients and analysed information gathered.

The practice had taken steps to improve environmental sustainability. They segregated waste and used digital records, where possible.

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 responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

The information and evidence presented during the assessment was not always clear and well documented.

Policies and procedures were regularly updated, however they did not always contain practice specific information. The health and safety risk assessment was not reflective of arrangements within the practice and did not identify potential hazards and control measures

There were ineffective processes for identifying and managing risks. The practice did not address recommendations from equipment survey reports in a timely manner. A risk assessment to identify and mitigate the risks associated with fire and Legionella within the boundaries of the practice had not been carried out. In addition, improvements were needed to ensure the management of risks associated with recruitment and the use of hazardous substances was effective.

Improvements were needed to the systems in place for quality assurance and continuous improvement. Staff had not received a recorded induction at the point of employment, and appraisals we looked at did not record individual learning and development needs. Improvements could be made to the systems in place for the oversight of staff training. Prior to our assessment not all staff had completed training in autism and learning disability awareness, fire safety, safeguarding and legionella.

The practice had carried out a radiography audit, however this did not have documented learning points and was not suitable to drive improvement. Improvements could be made to ensure that record keeping audits and antimicrobial prescribing audits were carried out.

The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts.

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.