Abbey Street 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. The provider had made improvements in relation to the regulatory breach we found at our inspection on 13 November 2023.

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.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises. At the assessment on 22 May 2024 we found the practice had made the following improvements to comply with the regulation: The provider had improved systems and processes to ensure they were operating effectively to assess, monitor and improve the quality and safety of the services being provided. The provider engaged with external companies to undertake risk assessments and acted on the recommendations of these. In particular, a new fire risk assessment had been carried out, and actions taken to ensure the safety of all building users and visitors. Improvements had been made to the decontamination facilities. The air extraction fan was working. A reverse osmosis water system and additional storage shelving had been installed, and surfaces were sealed to ensure effective cleaning. There was improved day to day management and oversight of the practice. For example, audits of infection prevention and control were now effective and the findings of these were analysed and acted on. Systems to audit the use of antimicrobials had been improved to ensure consistency of prescribing amongst the clinicians.

At the assessment on 22 May 2024 we found the practice had made the following improvements to comply with the regulation: There was an effective process to ensure medical emergency arrangements and checking processes were in line with Resuscitation Council UK guidance. The practice’s infection prevention and control policy and procedures were now applicable to the equipment in use. Processes had been simplified and clearly displayed, and we saw staff followed these to ensure instruments were decontaminated, stored and reprocessed in line with guidance. Systems were in place to obtain evidence of immunity to Hepatitis B for all clinical staff. Risk assessments and booster vaccinations were in place where immunity levels were lower than the recommended levels. Sharps safety processes were in place, including procedures to access advice and follow up in the event of an inoculation injury. Incident reporting systems had been improved to ensure staff followed the incident reporting policy to document and investigate these. The required radiation protection information was available and a damaged X-ray unit had been fixed. The operators’ instructions now included information about the controlled zone and mirrors had been installed to enable operators to view the patient and control panel whilst taking X-rays. Systems were in place to ensure all hazardous substances were risk assessed and appropriate information was provided to cleaning staff about the substances they used. The practice had also made further improvements: Systems had been improved to enable staff to ensure the security and tracking of NHS prescriptions. Protocols for the use of closed-circuit television cameras had been improved taking into account the guidelines published by the Information Commissioner's Office.

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.