Great Cornard 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.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 27 January 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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 inspection on 22 January 2026, we found the practice had made some improvements, however these were neither embedded nor sufficient to comply with the regulation:

There was a lack of systems to ensure effective governance and oversight of quality assurance and monitoring and mitigating risk of the service. This resulted in risks not being identified or adequately managed with the potential to impact upon the delivery of well-led care. There were insufficient processes for identification of risk for fire, medical emergencies and legionella.

There were ineffective systems in place to ensure that recruitment procedures complied with the requirements of the regulation. Not all necessary information relevant to staff employment in the role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were in place.

The practice had a Recruitment Policy and Procedure, outlining the formal framework for selecting and hiring employees, the practice was not following its own recruitment policy and meeting these requirements.

The policy stated that written offers of employment would be made subject to 2 satisfactory references, (clinical for dentists and Dental Care Professionals (DCP)) proof of entitlement to work in the UK, proof of GDC registration, dentists and DCPs health screening and immunisation, disclosure and barring service checks.

Evidence of immunisation against the Hepatitis B virus including the level of response (titre levels) were not in place. Not all staff had undertaken a full course of vaccinations since this was identified in the 27 January 2025 inspection. For staff who had not responded to the vaccine, or where evidence of immunity was unavailable, there were no risk assessments in place.

Enhanced disclosure and barring service (DBS) checks for the 3 trainee dental nurses working at the practice had not been undertaken. We noted the practice had recently (14 January 2026) applied for enhanced DBS checks for all 3 trainee dental nurses.

We noted Enhanced DBS risk assessments had been undertaken for all 3 staff on the day of our follow up inspection 22 January 2026.

There was no risk assessment in place for a member of staff who was pregnant.

From our discussions with staff and the lack of evidence provided following our discussions with the provider, both during and after our inspection, we were not assured that an induction process was undertaken with new members of staff, or what areas were discussed with staff during these inductions.

Staff had limited understanding of what procedures they should follow in the decontamination room.

The system to monitor and track the training of staff was ineffective. We asked, but were not provided with evidence that all 3 staff had received training in infection prevention and control, Legionella, fire safety, autism and learning disability and complaints.

Staff had not received an appraisal.

Audit systems were not in place to support continuous improvement of the care provided to service users. Infection prevention and control and radiation audits were not undertaken.

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.