Exceldent

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.

During our assessment of this key question, we found

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided and

a lack of systems or processes 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 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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 were not assured that the responsible person understood their roles and responsibilities to support good governance and management. They were not always aware of the legal requirements, the compliance arrangements within the practice or where certain policies and risk assessments were kept.

The provider told us that shortcomings we identified in relation to infection prevention and control and record keeping were due to their lack of capacity to oversee and manage all aspects of the service alone. We were not assured that the provider had suitably identified the risks arising from working without chairside support and the impact this had on their ability to provide safe, effective and high quality care.

The information and evidence presented during the assessment was not clear or well documented.

The practice did not have an effective governance system. Protocols and procedures were not tailored to the service or reviewed on a regular basis.

The practice did not have an up-to-date disability access audit and there was no action plan to continuously improve access to patients.

There was no documented evidence that the provider had sought the views of patients about their experience and the quality of care and treatment delivered by the service.

There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with fire, medicines management, Legionella, infection prevention and control, control of substances hazardous to health, medical emergencies, sharps, radiation safety, lone working and appropriate staffing levels.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. The provider could not demonstrate that they carried out audits for infection prevention and control and radiography, to support continuous improvement of the care provided to service users. In the absence of an effective audit program, the provider was unable to identify areas for improvement or take prompt action to improve the quality, effectiveness and safety of services.

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.