Chester Road 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 the provider has made the required improvements. During our assessment of this key question, we found systems and 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 were not effective. 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 report 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. The practice staff demonstrated a transparent and open culture. They were responsive to discussion and feedback to highlight risks and took appropriate action to address these. Staff told us they had clear responsibilities, roles and systems of accountability to support good 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 effective processes to support and develop staff with additional roles and responsibilities. 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. For example, the practice recycled where possible, reduced paper use by implementing digital systems, and turned off equipment and lights when not in use.

The practice’s processes for identifying and managing risks, were not always effective. Improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire safety, Legionella, and radiation protection, medicines dispensing and the oversight of medical emergency arrangements. At the time of the assessment, the practice had governance systems which included policies, protocols and procedures, but these were difficult to find, not easily accessible for all staff and were not consistently followed. Improvements were required to ensure oversight of all governance systems. The provider had recently appointed a clinical manager and was in the process of reviewing and improving the governance systems, this was yet to be embedded. The practice had ineffective systems for receiving and acting on patient safety alerts, recalls and rapid response reports. Improvements were required to ensure the practice responded to concerns and complaints appropriately and consistently followed their complaints procedure. The practice had ineffective systems to review and investigate incidents and accidents. In particular, there was no evidence the practice had an incident and accident reporting policy. Improvements were required to the systems and processes for learning, quality assurance and continuous improvement. The practice conducted audits of clinical records, radiography, infection prevention and control and reasonable adjustments. However, improvements were required to the radiography audit to ensure the sample size is in line with recognised guidance. 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 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.