Western Avenue 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 the registered person to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the effectiveness 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 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 demonstrated a transparent and open culture in relation to people’s safety. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. 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, 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. We saw the practice had some processes to support and develop staff, however due to capacity issues the full range of support that would be expected for a trainee and new staff should have been receiving was limited. The trainee dental nurse was not receiving support in line with guidance. Staff told us how they collected and responded to feedback from patients, the public and external partners. We noted that not all feedback provided to the practice by patients had been responded to. We discussed this and staff told us they would ensure al future feedback was responded to.

The information and evidence presented during the assessment was clear and well documented. However, there were gaps in the practice’s ability to present all relevant information. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. The filing systems for policies and procedures was haphazard and required improvements. Some documents could not be located on the day of the inspection and documents were saved in different places which meant that when we requested them there were not readily available to the inspection team. Documents such as the full COSHH folder, and data safety sheets, antimicrobial prescribing audit, fire risk assessment could not be located on the day and were provided after the inspection. Relevant policies and protocols were not in place for the use of closed-circuit television (CCTV). There was no signage advising patients and visitors that it was installed and they did not have the relevant data protection policies and risk assessments for the use of recording equipment. 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 systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. The radiograph and disability access audits could not be located on the day of the inspection but the provider assured us they had been completed.

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.