Dental Arts - Harrogate Also known as Ace Denta 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 a lack of systems or processes and some ineffective systems that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided, 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 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 there was a lack of leadership and oversight to assess, monitor and improve the quality and safety of services provided, which led to the issues highlighted by the on-site assessment. However, we found staff to be open to discussion and feedback to make the necessary improvements to ensure people’s safety. Staff needed clarity on their responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through informal discussions. Staff stated they felt respected and valued and were proud to work in the practice. Staff told us how they collected and responded to feedback from patients, the public and external partners.

Systems and processes were not embedded, and the assessment highlighted significant issues and omissions. Where the assessment identified areas which required improvement, some were acted on immediately. The information and evidence presented during the assessment was not clear nor well documented. The governance system including policies, protocols and procedures was not ineffective. Systems to ensure appropriate arrangements to enable timely response to a medical emergency were ineffective. This was highlighted by many items of the medical emergency kit being out of date or missing (including adrenaline). There was a lack of oversight and knowledge of the requirements of the Resuscitation Council UK guidance. There was no evidence any action had been taken to replace emergency medicines that staff knew had expired. There was no effective process to review and comply with relevant Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS). Alerts were received by email, but we saw these were not read, including an alert that was relevant to the practice regarding batches of a prescription medicine that had incomplete allergen information on the accompanying patient information leaflets. The practice did not have effective systems in place to assess, monitor and improve the quality and safety of the services being provided. Required infection prevention and control audits and record-keeping audits were not completed. The radiography audit was ineffective as it had not identified lack of justification or reporting on radiographs within the clinical records. The radiography audit had not been reviewed and there was no evidence of conclusions, action plans or sharing of learning. Staff responsible for radiography audits did not have appropriate training or knowledge to enable them to do this effectively.

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.