Elbow Lane Dental Care

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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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 practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Systems and processes were mostly effective. The inspection identified some areas where governance and oversight could be strengthened. These included medicines management, maintenance of recruitment and training records for visiting clinicians, monitoring of daily safety checks, emergency medicines oversight and sedation governance.

During the inspection, leaders responded positively to feedback and took immediate action where concerns were identified. They demonstrated a willingness to strengthen governance systems and provide additional evidence following the inspection to support compliance.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We noted innovative approaches to providing person-centred care. For example, staff provided tailored support for elderly patients and those living with dementia, including appointment reminder calls, arranging transport, and offering reassurance while patients waited for appointments. This helped reduce anxiety, improve access to care, and ensure patients felt valued and supported.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys, 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. For example, following feedback from a recent staff survey, the practice increased preparation time within clinics to reduce staff feeling rushed and support the delivery of safe, effective care. Staff also requested new uniforms, which were provided.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, following feedback from patients requesting more regular communication and information, the practice introduced a monthly newsletter. This provided updates on practice developments, such as new clinicians joining the team, as well as information on relevant national health topics, including mental health and other health promotion initiatives, which helped patients stay informed about practice developments and wider health issues.

The practice had taken steps to improve environmental sustainability, including increasing the use of digital systems, promoting recycling and implementing stock control processes to reduce waste and unnecessary ordering.

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.