Friar Street 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 a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. They did not have effective systems to ensure recruitment processes were followed, dental records were not stored securely and they had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office. 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.

Improvements were needed to the oversight of the practice and to ensure information about systems and processes were embedded in the day to day running of the practice. This assessment highlighted a number of issues and omissions such as those relating to fire safety management, equipment and premises, emergency medicines and equipment, hazardous substances, infection prevention and control, waste management, staff recruitment, training and legionella management. Staff feedback was obtained through meetings and informal discussions. Patient feedback was obtained but this was not collated or reported on. A general data protection regulation (GDPR) compliant accident book was not available. A closed-circuit television (CCTV) privacy impact assessment was not available. A CCTV privacy notice which included rationale for the CCTV and contact details of the data controller was not available for patients and visitors. NHS patient identifiable records were not stored securely. The most current infection prevention and control audit did not reflect current practice. In particular, sharps processes, hand hygiene and 'bare below the elbow' protocols for clinical staff. The practice carried out dental treatment under intravenous (IV) sedation. The provider did not assure themselves this was done safely. Following discussion, the provider formally advised us that the practice has ceased all sedation services indefinitely. A business continuity plan was available. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice had systems in place to respond to concerns and complaints appropriately, although not all patients were aware how to complain.

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.