Friars 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 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. We also found concerns around the ineffectiveness 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 Regulations 17, 18 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.

During the assessment we found staff to be open to discussion and feedback. Feedback from staff was obtained through meetings and informal discussions. However, these were not always documented or available for review during the assessment. Following the assessment we saw evidence of recent documented team meetings. Staff told us there was strong emphasis on people’s safety.

Systems and processes to support effective governance and oversight were not embedded. Where the assessment identified areas which required improvement, some of these were acted on immediately and the provider and staff demonstrated a commitment to addressing issues identified. During the assessment process information and evidence was not always present. Information and evidence that was presented during the assessment was not always clear and well documented. The practice had a governance system which included policies, protocols and procedures. We found that these were not stored in a way that made them easily accessible to all members of staff as these were locked in the practice manager’s office and only the registered manager had access to the keys. 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). Processes for identifying and mitigating risks, issues and performance were not always clear and effective. The practice’s systems and processes for learning, quality assurance and continuous improvement were not established or effective. Radiography and decontamination equipment were not always maintained in line with manufacturers guidance and required pre-employment recruitment checks were not available.

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.