Olive 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 that: The registered person had systems or processes that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate the risks relating to the safe and effective recruitment of staff, and other risks related to undertaking of regulated activities such as fire safety, lone working, hepatitis B immunity, management of medicines and medical emergency equipment and radiography. 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.

During the inspection 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. Staff stated they felt respected, supported and valued, and they were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they collected and responded to feedback from patients, the public and external partners. The NHS Friends and Family Test was available to patients in the reception, and there was a suggestion box in the waiting area. The outcome of this feedback was reviewed and discussed with staff to ensure improvement.

During the assessment process, some information and evidence was not present and needed to be requested from suppliers. The practice did not have a copy of servicing for the 3 X-ray machines, there was no evidence of critical examination for the ground floor X-ray machine. The servicing of this equipment had to be actioned following the assessment. Medical emergency equipment was either missing or did not have clear expiry dates. Fridge temperatures where medicines were stored were not checked. We noted loose un-pouched items and loose local anaesthetics cartridges not in blister packs in treatment room drawers. There was no fire risk assessment and no evidence seen of an effective means of fire detection, and evacuation. Staff immunity to Hepatitis B was not documented in staff records, NHS prescriptions were not logged or stored securely. We saw areas that required improvement were acted on immediately. Improvements were needed to the oversight of the practice and to ensure information about systems and processes was readily available and embedded. The processes for identifying and managing risks were not effective, with no risk assessments in place for lone working staff or staff hepatitis B immunity. There was scope to improve the systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. Audits were being undertaken, but not all of these were at the required frequency for example, infection prevention and control and radiography. The practice had completed an antimicrobial prescribing audit, but this was not dated and there was no action plan in place. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

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.