Ormond Terrace Dental

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.

At the time of the assessment there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered.

During our assessment of this key question, we found the provider had systems or processes that operated ineffectively in that they failed to enable them 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 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.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. We found that systems and processes in place did not give the provider the oversight required for the effective running of the practice. When giving feedback following our assessment, staff and managers were open and responsive to our findings and took some immediate actions to mitigate risk. Other areas for improvement were assigned to staff and are being addressed. Systems and processes were not embedded and were not routinely followed by all. 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.

There were processes for undertaking audits, but these were not always effective in identifying and managing risks, for example, in relation to infection control and audit of patient records. Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. Staff had clear responsibilities, and systems of accountability to support good governance. However, these were not routinely adhered to. For example, in relation to staff recruitment, staff training records, management and oversight of staff training, in the audit of checks on emergency equipment, in the systematic review of audits undertaken and the sharing of learning points, and checks of the building for up to date signage. Collectively this meant the provider did not have sufficient oversight of the day to day management within the practice.

Staff feedback was obtained through meetings, surveys, 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.

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.