Queensgate 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 providing well led care in accordance with the relevant regulations and had taken into consideration appropriate guidance. The provider had made improvements in relation to the regulatory breach we found at our assessment on 13 March 2024.

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.

Feedback from staff and leaders Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises. At the assessment on 10 October 2024, we found the practice had made the following improvements to comply with the regulation. There was leadership with emphasis on peoples’ safety and continually striving to improve. The provider now had systems to ensure appropriate radiation protection information was held. Operators completed up to date training in accordance with The Ionising Radiation (Medical Exposure) Regulations 2017. Local rules and operators’ instructions were up to date and available. The practice had systems and processes for learning, quality assurance and continuous improvement. These included audits of patient care records, radiographs and antimicrobial prescribing. We highlighted where further improvements could be made to these. In particular, ensuring sufficient audit data is collected and analysed to highlight any issues, and documenting conclusions, reflections and action plans to demonstrate improvement. We saw improvements had been made to the documentation in dental care records in response to our feedback from the last assessment. The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. Staff including agency staff received a suitable structured induction. The provider did not obtain evidence of up-to-date checks on agency staff prior to them working in the practice. For example, some of these documents including professional indemnity were from 2021. The manager assured us this would be rectified and sent up to date evidence obtained during and after the assessment day. The practice did not have systems to obtain evidence that clinical staff had their immunity to blood-borne viruses tested in a timely way. The manager confirmed this would be rectified, we signposted them to guidance to support this action.

Processes We reviewed the processes for managing risks, issues and performance: The practice had improved processes to ensure instruments and devices were decontaminated in line with manufacturer’s guidance. Staff measured the correct ratio of instrument cleaning detergent and water to ensure this was effective. Staff completed the relevant validation tests on the steriliser, and ventilation in the decontamination room was now working. The dental implant motor was serviced annually, and we saw a system to ensure dental implant drills were decontaminated in line with manufacturer’s instructions. Staff using dental cone beam computed tomography (CBCT) had received the appropriate training to operate the equipment and report on images. As a result, we saw these were appropriately justified and reported on in line with nationally agreed guidance. Processes to enable staff to view patients during scans in response to Radiation Protection Advisor (RPA) recommendations were operating effectively. Systems were in place for appropriate and safe handling of medicines. The practice held stocks of antimicrobials which were dispensed to patients directly by the dentists. There were systems to control stock and monitor expiry dates and batch numbers. Patients were provided with a copy of the Patient Information Leaflet for the medicines dispensed. The practice had also made further improvements: There were processes for staff to access interpreter services for patients who do not speak English as their first language. Dentists were aware of, and followed the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment to protect the airway.

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.