Premium 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 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, the registered person had systems or processes that operated ineffectively in that they failed to enable them 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 assessment 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 lack of oversight of training, ineffective risk management and not adhering to published guidance in respect of infection prevention and control all 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. The information and evidence presented during the assessment was not always clear and well documented. Policies and procedures were not regularly updated and often contained out of date or not practice specific information. The Health and Safety risk assessment was not reflective of arrangements within the practice. For example, it stated that staff were trained in infection control, referred to amalgam usage (although we were told the practice did not use amalgam), stated that records in relation to legionella management were kept, and referred to an X-ray processing unit that was no longer used. Overall, we were not assured that policies included relevant and up to date information staff could confidently refer to.

Feedback from staff was obtained through meetings, surveys, 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. 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 taken steps to improve environmental sustainability. They segregated waste and used digital communications tools where possible. There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with fire, infection prevention and control, sharps, legionella, lone working and the monitoring of training. 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 ineffective systems and processes for learning, quality assurance and continuous improvement. There were no systems in place for the monitoring of training to ensure appropriate action could be taken quickly when training requirements were not being met. The infection prevention and control audit was not carried out bi-annually, in line with the current guidance. It included statements that were not substantiated by our findings, and it was not suitable to drive continuous improvement.

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.