Ewood House 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 the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided. 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. They did not have effective systems to ensure dental records were stored securely. 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 they had clear responsibilities, roles and systems of accountability to support the management of the practice. Feedback from staff was obtained through meetings, surveys, and informal discussions. Staff were encouraged to offer suggestions for improvements to the service and told us of a recent group-wide staff survey had been undertaken. The practice had not received feedback on the outcome of the survey and any learning from results had not yet been shared within the group. We were told they would follow this up. The team included longstanding members of staff. They told us they liked working at the practice and felt like a family. We saw the practice had processes to develop staff with additional roles and responsibilities. However, we noted more structured support and training may be required to ensure senior staff members were able to carry out the extra duties appropriately. Staff told us how they collected and responded to feedback from patients.

The assessment highlighted areas where improvements were needed, such as risk management and adherence to published guidance. Improvements should be made to the oversight of the leadership team to ensure that the practice’s clinical governance systems and processes were followed and risks managed appropriately. The practice’s information governance arrangements needed improvements to ensure all patients’ electronic care records were password protected when the computer was not in use and that paper records were stored securely to comply with General Data Protection Regulations (GDPR). On the day we saw patient records were not consistently stored securely and were accessible to unauthorised persons. Improvements were needed to ensure processes for managing risks were effective. The practice did not have adequate systems in place for identifying, assessing and mitigating risks in areas such as the completion of risk assessments, recruitment, medicines management and legionella. The practice’s systems and processes for learning, quality assurance and continuous improvement, needed improvements to ensure audits undertaken were a reflection of the current protocols at the practice. The audits had not identified the required improvements highlighted within our assessment. However, the information and evidence presented during the inspection process was clear and well documented. The practice’s policies, protocols and procedures were accessible to all members of staff. Audits were undertaken according to recognised guidance. Staff were aware of the importance of protecting patients’ personal information. 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 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.