Swakeleys 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 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 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. We were not assured that leaders understood their roles and responsibilities to support good governance and management. They were not always aware of the legal requirements, the compliance arrangements within the practice or where certain policies and risk assessments were kept. The provider appointed a lead for governance and compliance related duties but had not allocated additional time for this role. Information was not always shared and cascaded effectively. Staff stated they felt respected, supported and valued. However, we were not assured that the practice had effective processes to support and develop staff, including trainee nurses. We identified gaps in staff`s knowledge, including infection prevention and control and sepsis. We noted that the provider had not identified that those they appointed to supervise trainee staff did not have the requisite skills and knowledge themselves. The information and evidence presented during the assessment was not always clear and well documented. Practice policies were detailed and regularly updated. However, these were not effectively embedded, and most staff members did not know where certain information, including safeguarding contact details, policies, risk assessments, audits and clinical waste consignment notes were kept. This meant that systems and processes within the practice were fragmented, and relevant information was not readily accessible to all members of staff.

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, sharps, radiation safety and recruitment. The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. The infection prevention and control audit completed in March 2024 was not reflective of our findings and was not suitable to drive improvement. The practice had an ongoing radiography quality log however an audit to identify trends and areas of improvement had not been carried out. The record card keeping audit was not aligned to the current guidance and did not highlight the record keeping issues our inspection identified. Feedback from staff was obtained through informal discussions. Staff told us that they were encouraged to offer suggestions for improvements to the service. The practice had taken steps to improve environmental sustainability. They segregated waste, used digital communications tools and reduced the use of plastic. 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 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 appropriately. Staff told us that they 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.