Beaulieu Dental Limited

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 that: The registered person had systems or processes that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate the risks relating to Good Governance of the practice. There was no fire risk assessment, no servicing of the emergency lighting or fire alarm systems. The Electrical Installation Condition Report was overdue. Risks identified in the Legionella risk assessment had not been reviewed or completed. The processes for overseeing staff training were not effective. Staff appraisals were not undertaken and there were no records to confirm staff inductions were undertaken. Audits were being undertaken, but not all of these were at the required frequency for example, infection prevention and control and radiography. 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.

During the assessment we found staff to be open to discussion and feedback. Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service. Staff stated they felt respected, supported and valued, and they were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they collected and responded to feedback from patients, the public and external partners. There was a suggestion box in the waiting area. The outcome of this feedback was reviewed and discussed with staff to ensure improvement.

During the assessment process, some information and evidence was not present and needed to be requested. At the time of the assessment there were no records for servicing of the compressor. This was provided following the assessment. There was no fire risk assessment and no evidence seen of servicing of the emergency lighting or fire alarm systems. The Electrical Installation Condition Report was overdue. The Legionella risk assessment highlighted 2 high risk and 1 medium risk action that had not been reviewed or completed. The processes for overseeing staff training were not effective. Staff appraisals were not undertaken and there were no records to confirm staff inductions were undertaken. We saw some areas that required improvement were acted on immediately. Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded. Audits were being undertaken, but not all of these were at the required frequency for example, infection prevention and control and radiography. The practice had an on-going antimicrobial prescribing audit. There was scope to improve the systems to review and investigate incidents and accidents. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. 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.