Stotfold Dental Practice - Stotfold

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 the safe and effective recruitment of staff, and other risks related to undertaking of regulated activities such as fire safety, management of medicines, lasers 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 inspection 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. 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 that they received online reviews from patients but did not illustrate how this feedback was evaluated.

During the inspection process, some information and evidence was not present and needed to be requested from suppliers. For example the practice did not have a copy of the Electrical Installation Condition Report to ensure the practice was safe. Following the inspection, we saw that this had been obtained. Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded in the day to day running of the practice. This assessment highlighted some issues and omissions such as relating to fire management, recruitment, management of medicines, and regarding lasers and radiography. Additionally, the business continuity plan had not been completely personalised to reflect the practice. Following the assessment, we saw that this had been updated. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice responded to concerns and complaints. Improvements could be made to ensure duty of candour principles were taken into account when responding to complaints. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance for example an IPC audit and a radiography audit.

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.