Lowton Dental Centre

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 the registered person 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 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. 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. Feedback from staff was obtained through meetings, and informal discussions. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff told us how they collected and responded to feedback from patients, the public and external partners.

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. Improvements could be made to ensure all policies reflect current protocols at the practice and to ensure a consent policy is implemented. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), but these did not reflect current protocols at the practice. We noted a Data Protection Impact Assessment (DPIA) had not been carried out to assess the purpose, necessity, and risks prior to installation of CCTV. Following the on-site assessment, the practice sent evidence that a DPIA had since been completed. Improvements could be made to the processes for identifying and managing risks, issues, and performance. In particular, the risks associated with fire, legionella and radiation. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. We noted, improvements could be made to ensure all incidents are recorded and follow-up actions are documented. We discussed what staff considered to be a significant event and were assured this would be addressed and rectified. The practice had procedures to respond to concerns and complaints appropriately. Improvements could be made to the systems and processes for learning, quality assurance and continuous improvement. The practice conducted audits of clinical records, radiography, infection prevention and control and reasonable adjustments. However, improvements could be made by increasing the sample size of the radiography audit in line with recognised guidance and ensuring there is an action plan for the reasonable adjustment audit to drive improvement.

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.