St Mark 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: 1. A lack of systems or processes that enabled the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk: 2. Systems or processes that operated ineffectively in that they failed to enable the registered person to evaluate and improve their practice in respect of the processing of the information obtained throughout the governance process: 3. The systems or processes in place operated ineffectively in that they failed to enable the registered person to seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services. 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.

The practice staff and provider did not demonstrate a transparent and open culture in relation to people’s safety. Feedback from staff was obtained through informal discussions. Prior to the inspection, the practice owner told us that practice meetings were held on a regular monthly basis. During the inspection, we were told, and we saw, that practice meetings were not held or documented. The last practice meeting minutes we were shown were dated 2018. We saw that patient feedback was now being requested, but we were told that there was no patient feedback prior to this inspection. We found that there was a lack of sufficient oversight and ineffective leadership which impacted the practice’s ability to deliver safe, high-quality care. Systems and processes were not embedded, and the assessment highlighted many significant issues. Following the inspection, some of these concerns were acted upon, however, multiple concerns remained. The information and evidence presented during the inspection process was not well documented. Significant improvements were needed to ensure that records in relation to the management and provision of regulated activities were readily available and easily accessible to all members of staff and those who would need to review them. The practice did not have effective governance and management arrangements. The practice did not have systems for receiving and acting on safety alerts.

We saw that there were multiple closed-circuit television (CCTV) cameras in the practice which recorded audio and visual images. Relevant policies and protocols were not in place for their usage. Signage informing patients about CCTV was not present. After feedback from the inspection, a CCTV policy was written, as was an annual CCTV checklist. However, these were contradictory and referred to images being kept for 30 days in the policy and for 60 days in the checklist. The CCTV policy also stated that there were cameras in the 4 surgeries which did not reflect our findings. There was no justification for auditory recordings. We were told that following completion of the refurbishment, a sign will be displayed. The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. The practice told us that no complaints had been received since 2021 and so we were unable to assess if the practice responded to concerns and complaints appropriately, and if outcomes were discussed to share learning and improve the service. No complaints policy was on display for patients, nor on the practice website, and the complaints policy dated 2023 referred to out of date addresses for further information. The practice did not have systems and processes for learning, quality assurance and continuous improvement, and the practice did not have any oversight of staff training. Additionally, audits were not undertaken according to recognised guidance, for example the IPC audit was completed annually, a radiograph audit was not being completed and the disability access audit had been completed for a different practice. The processes for managing risks were wholly ineffective. The practice did not have adequate systems in place for identifying, assessing and mitigating risks in multiple areas.

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.