Antwerp House 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 concerns related to the assessment, monitoring and mitigation of the risks relating to the health, safety and welfare of service users and others who may be at risk which arose from the carrying on of the regulated activity, the maintenance of such other records as were necessary to be kept in relation to—(i) persons employed in the carrying on of the regulated activity, and (ii) the management of the regulated activity, and seeking and acting on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services. These 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 report 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.

Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded in the day to day running of the practice.

The inspection highlighted some issues and omissions relating to fire safety, legionella management, the maintenance of equipment, completion of risk assessments, staff training, recruitment, radiography and lasers.

The information and evidence presented during the inspection process was limited and following the inspection, multiple items were sent to us to demonstrate improvements. However, some of these updated documents still lacked sufficient detail or information to assure us that all policies were comprehensive, or that all risks had been considered and assessed. For example, the newly updated health and safety risk assessment referred to the use of CCTV which was not present, that pressure vessels were routinely examined and that annual electromechanical checks of the intraoral radiography units were completed, yet these were not completed for the practice.

Feedback from staff was not regularly requested. We were told that practice meetings were not held, and staff communication was limited, mainly through the use of mobile phones.

Staff told us that feedback from patients was not requested by the service.

The practice had taken steps to improve environmental sustainability. For example energy efficient lighting was used, paper usage was reduced through the use of digital systems and waste was recycled where appropriate.

The practice did not have an effective governance system in place to review policies, protocols and procedures on a regular basis.

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.

We saw there were ineffective processes for identifying and managing risks, issues and performance which resulted in multiple areas of concern following the inspection.

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 discussed outcomes to share learning and improve the service.

The practice did not have effective systems or processes in place for learning, quality assurance and continuous improvement. Mandatory audits for example the radiograph audit and IPC audit were not being completed in line with guidance.

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.