Church Road 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 the provider had made the required improvements.

During our inspection of this key question, we found a lack of effective processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided.

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 provider’s oversight of regulatory requirements required improvement.

These concerns were in breach of Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems and processes were not embedded among staff which highlighted a number of issues which included, recruitment, control of substances hazardous to health, Legionella, complaints, infection prevention and control, and fire safety management.

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 (GDPR).

The practice had a governance system that included policies and procedures, which were accessible to staff. We found that policies were not reviewed on a regular basis.

Information was available for patients who wished to feedback concerns and complaints. Improvement was needed to establish an effective system for recording, handling and responding to concerns and complaints.

The management of accident and complaint records did not comply with General Data Protection Regulation requirements.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking radiography and infection prevention audits according to recognised guidance and legislation. The practice should ensure that the results of audits are fed back to individual clinicians so that learning points could be addressed.

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 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.