A & D Dental Practice Ltd

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. 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. The practice staff and provider demonstrated a commitment to developing a transparent and open culture in relation to people’s safety. We found this was not embedded in practice life at the time of our inspection. 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 informal discussions, records of these meetings were not always available. Staff were encouraged to offer suggestions for improvements to the service.

Systems and processes to support effective governance and oversight were not embedded. Where the assessment identified areas which required improvement, some of these were acted on immediately and the provider and staff demonstrated a commitment to addressing all issues identified. 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. We found that these were not stored in a way that made them easily accessible to all members of staff. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV). We noted that clear signage warning of the presence and use of CCTV was not displayed prominently at the service. Following our inspection the provider submitted evidence that signage had been purchased and displayed. 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). Processes for identifying and mitigating risks, issues and performance were not always clear and effective. 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. The practice systems and processes for learning, quality assurance and continuous improvement were not established or effective. Audits of infection prevention and control, radiography, record keeping and antimicrobial prescribing were not carried out in recommended timescales or in line with recognised guidance. Radiography equipment was not always maintained in line with manufacturers guidance and pre employment recruitment checks were not kept.

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.