Parish 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

systems and processes to assess, monitor and improve the quality and safety of the services being provided were not effective.

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 were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

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’s governance system was not always effective. Documents relating to radiation protection had not been adapted to the practice. In addition, the procedure for checking medical emergency equipment was not working effectively to ensure everything was within the expiry date.

Improvements were required to the system for identifying and managing risks, issues and performance. These included the risks associated with fire and hazardous substances.

The system to review and investigate incidents and accidents were not always effective. Improvements were required to the system for learning from significant events. We saw 2 incidents where there was no evidence of learning from the events. However, both incidents had been followed up appropriately.

The practice’s systems and processes for responded to concerns and complaints were not always effective. Improvements were required to the system for maintaining details of correspondence of all complaints. We discussed this with staff and were assured it would be addressed and rectified.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Improvements could be made to the audit process to ensure action plans and learning outcomes are documented for all audits. We discussed this with staff and were assured it would be addressed and rectified.

However, policies, protocols and procedures were accessible to all members of staff.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

The practice had systems for receiving and acting on safety alerts.

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 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.