Southbrook 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 mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. The registered person had not ensured that all the information specified in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was available for each person employed. This resulted in a breach of Regulations 17 and 19 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.

The practice staff demonstrated a transparent and open attitude towards the assessment process and were open and honest to discussion and feedback, as well as about issues identified. Feedback from staff was obtained through 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 processes to support and develop staff with additional roles and responsibilities. However, improvements must be made to the oversight of this development. Staff told us how they collected and responded to feedback from patients, the public and external partners. We saw evidence of feedback which had been given. This was positive about the service provided and the caring and attentive nature of the staff. It was clear that patients were happy with the service provided. 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 systems to respond to concerns and complaints appropriately. Improvements must be made to the overarching governance system. Not all policies and procedures were available on the day of assessment. In particular, for recruitment, complaints, incident investigation, consent, whistleblowing and the use and processing of images from closed-circuit television system (CCTV). Those which were available had not been reviewed regularly and some referred to out-of-date guidance.

Systems and processes were not working effectively to ensure the risks associated with the carrying on of the regulated activities were appropriately managed. Where the assessment identified areas requiring improvements, these were acted on immediately and evidence was submitted to support this. The provider demonstrated a desire to embed new systems and processes to prevent reoccurrence of these issues. Not all evidence was available on the day of the on-site assessment. Some documentation was sent after the on-site assessment and other evidence had to be completed after the on-site assessment. Improvements must be made to the processes for identifying and managing risks, issues and performance. These include the oversight of safe staff recruitment, staff training and the risks associated with fire and Legionella. The practice had systems to review and investigate incidents and accidents. We asked staff about the process for receiving and acting on safety alerts. We were informed that no safety alerts had been received recently. We discussed this with staff and were assured the system for receiving these would be reviewed. Improvements must be made to the systems and processes for learning, quality assurance and continuous improvement. We asked staff if any audits had been carried out to continually improve the quality and safety of the service being provided. We were informed no full audits of radiography or infection prevention, and control had been completed within the last year. Effective quality assurance processes could have helped identify areas of improvement we found on the day of assessment.

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.