Wraysbury 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 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 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 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.

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, and they said these were listened to and acted upon, where appropriate. 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 provider’s oversight of regulatory requirements required improvement. The provider acknowledged that there was a lack of proactive action to comply with the regulations.

Improvements were needed to the oversight of the practice and to ensure information about systems and processes were embedded in the day to day running of the practice. During the inspection process, some information and evidence was not available and needed to be located by the provider. This assessment highlighted a number of issues and omissions such as relating to fire management, equipment and premises, hazardous substances, infection prevention and control, waste management, record keeping, staff recruitment and training and legionella management. A GDPR compliant accident book not available. The provider's employer liability certificate was not available. The practice did not operate an effective governance system which included policies, protocols and procedures. A number of policies presented to us were dated 2008 with no evidence of a review since. A business continuity plan was not available. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice had systems in place to respond to concerns and complaints appropriately.

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.