Welwyn 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. The registered person also 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. 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 report 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 provider was receptive to feedback on areas where improvement was needed and provided evidence to show where immediate action had been taken to address the concerns identified. The practice staff demonstrated a transparent and open culture in relation to people’s safety. However, improved oversight was needed to ensure there was an understanding of the essential requirements and regulations. We found the provider had the values and commitment to deliver high quality sustainable services. However, the lack of oversight of training, ineffective risk management and not always adhering to published guidance in respect of infection prevention and control all impacted the day-to-day management of the service. 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 and knew their roles and responsibilities. The practice had a complaints policy and processes to respond to concerns and complaints appropriately. Staff told us that although no complaints had been received, they would have discussed outcomes to share learning and improve the service. The practice had taken steps to improve environmental sustainability. For example, by recycling where appropriate.

The information and evidence presented during the assessment was not always clear, available and well documented. Policies and procedures were generic and often contained information which was not relevant or practice specific. For example, the external contact details for staff to share a concern in the whistleblowing policy was out of date. The health and safety risk assessment was not practice specific or reflective of all risks within the practice. For example, it had not identified the risks posed to staff by the damaged stair carpet and the sharps risk assessment did not include information about any control measures in place. Overall, we were not assured that policies included relevant and up-to-date information staff could confidently refer to. The practice had some systems to review and investigate incidents and accidents. However, there were no processes for receiving and acting on safety alerts. There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with fire, infection prevention and control, legionella, radiation, lone working, recruitment and training monitoring. The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Audits for radiography, record keeping, antimicrobial prescribing and disability access were not completed. Infection prevention control audits were ineffective and were not undertaken at the required frequency. There were no systems in place for monitoring training to ensure that all staff received training appropriate to their role at required frequencies. However, 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 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.