Greg Gossayn Dental Surgery

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 a lack of systems or processes that enabled the provider to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of 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 detailed 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.

The practice did not have an effective governance system. Systems and processes were not embedded. While there were some policies and procedures which were accessible to staff, these were not sufficient to ensure patient safety and regulatory compliance. We were informed that the practice had recently enrolled with a dental compliance company to help with the future governance arrangements in the practice. There were ineffective processes for identifying and managing risks. The practice had failed to carry out risk assessments to assess and mitigate the risks associate with the use of radiation, fire safety, use of sharps, medical emergencies, lone working, or Control of Substances Hazardous to Health (COSHH). In addition, the practice did not have any systems for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency. The practice did not have a business continuity plan, to help identify and plan for anticipated risks to the delivery of the service. The practice had ineffective systems in place for quality assurance and continuous improvement. The practice did not carry out any audits of infection prevention and control, antimicrobial prescribing or record keeping. The practice had completed a radiography audit, but this did not have any documented learning points and had not recognised that the grading of the radiographs was not in line with current guidance. The practice had failed to carry out a disability access audit. Where the assessment highlighted significant issues, the practice took some action to address these concerns immediately. Staff demonstrated an open culture in relation to people’s safety and wanted to demonstrate improvement.

Staff were aware of the importance of protecting patients’ personal information. Paper records were stored securely and staff password protected patients’ electronic care records to comply with General Data Protection Regulations. The practice had systems in place so that concerns and complaints were responded to appropriately. The practice had not received a complaint in the 12 months prior to our assessment. We were told that complaints would be discussed amongst staff members, so that areas of improvement could be identified and acted on. The practice had systems in place to record and investigate incidents and accidents. Staff feedback was obtained through informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were mostly listened to and acted upon, where appropriate. Feedback from patients was collected through feedback forms and a suggestion box. The practice had taken steps to improve environmental sustainability. For example, by turning off lights and equipment when not in use.

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.