Paragondental

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 the provider had made the required improvements. During our assessment of this key question, we found that the practice had ineffective systems or processes that failed to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, oversight of fire safety, medicines management, emergency medicine and equipment and staff recruitment. 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 detailed 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 to ensure that it was consistently well-led for patients and staff.

Staff told us there was strong leadership with emphasis on people’s safety and a positive experience of the practice for patients. However, improved oversight was needed to ensure there was an understanding of the essential requirements and regulations and that changes made to policies and procedures were embedded.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were usually listened to and acted upon, where appropriate. However, staff had not been provided with a structured induction or annual appraisal.

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. For example, through online reviews.

The practice had taken steps to improve environmental sustainability. For example, they segregated general waste and clinical care records were digital.

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.

However, the information and evidence presented during the assessment was not always readily available, clear and well documented. Some governance arrangements needed strengthening to ensure that the availability and checking process of emergency medicines and equipment were robust, that recruitment checks were present and that records were maintained for fire safety checks and evacuation drills and the safe use of medicines.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records and complied with General Data Protection Regulations.

We saw the processes in place were not effective for identifying and managing all risks, issues and performance in particular regarding staff performance, management of fire safety and oversight of medical emergency equipment.

There was no system or process to manage, identify or dispose of out-of-date stock. We saw that multiple expired products were present in the treatment rooms. Following the inspection, we were told these had been replaced.

There were some processes for investigating incidents and accidents. At the time of the assessment the practice did not have an effective system for receiving and acting on safety alerts. Following our feedback the provider signed up to receive these through email.

The practice has systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, improvement could be made by including an antimicrobial prescribing audit.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

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.