Globe Dental Practice

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• 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 the provider has made the required improvements.

During our assessment of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of systems or processes 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 assessment 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.

Feedback from staff was obtained through meetings and informal discussions.

Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, patients receive a feedback link in an email after their appointment.

Where the assessment identified areas which required improvement, the provider submitted some evidence following the assessment providing us with some assurance that the provider was implementing improvements, these were yet to be embedded. Some evidence submitted highlighted that systems were ineffective. For example, when staff checked 2 of the smoke alarms and the fridge thermometer after the assessment, they identified the batteries required changing.

The processes for identifying and managing risks, were not always effective. Improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire, radiation, health and safety, sharps safety, and fit and proper persons employed.

At the time of the assessment, the practice had governance systems which included policies, protocols and procedures, but these were difficult to find, not easily accessible for all staff and were not consistently followed or regularly reviewed. Improvements were required to ensure oversight of all governance systems.

Improvements were required to the systems to review and investigate incidents and accidents. In particular, ensuring all follow-up actions are documented, including evidence of shared learning and ensuring the accident slips containing confidential information are stored securely. In particular, ensuring appropriate advice is sought and followed for sharps incidents.

Improvements were required to ensure the practice responded to and documented concerns and complaints appropriately.



Staff password protected patients’ electronic care records and complied with General Data Protection Regulations (GDPR).

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

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.