St Mark Dental Surgery

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. The provider had made insufficient improvements to put right the shortfalls we found at our inspection on 11 November 2024. We have told the provider to take action. We will be following up on our concerns to ensure they have been put right by the provider. We found that the registered person had systems or processes in place that operated ineffectively in that they 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 relating to fire safety, sharps safety and hazardous materials. The registered person had systems or processes in place that were operating ineffectively in that they failed to enable the registered person to assess, monitor and improve the quality and safety of the services being provided. In particular in relation to complaints management and the audit of infection prevention and control processes.

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.

At the assessment on 6 January 2025 we found the practice had made the following improvements to comply with the regulations: The fire extinguishers were serviced in line with regulations and staff had completed fire safety training. We saw that fire alarms had been serviced on 9 November 2024. The logbook used for recording tests of the fire systems was blank. Following the inspection, the provider sent a logbook with recorded tests of fire alarms and emergency lights. Further improvements were required to ensure that fire drills and actions arising from the fire safety risk assessment were carried out and documented, and that emergency lighting was managed according to regulations. We saw that relevant policies and protocols were in place for the use of closed-circuit television (CCTV) cameras. Signage informing patients was also present. The complaints policy had been updated; however, further improvements were required as no information was on display for patients. We saw that an infection prevention and control (IPC) audit had been completed by the provider, yet this was undated and multiple questions were unanswered. The disability access audit had been updated and was reflective of the service. The sharps risk assessment had not been updated The risk assessments to minimise the risk that could be caused from substances that are hazardous to health had not been updated. We found that there was still a lack of sufficient oversight and effective leadership which impacted the practice’s ability to deliver safe, high-quality care. The information and evidence presented during the inspection process was not always readily available and many documents were not held onsite. Improvements were required to ensure that records in relation to the management and provision of regulated activities were available and accessible to all members of staff and those who would need to review them. The practice did not have wholly effective governance and management arrangements.

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.