York 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

the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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 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.

We found that the provider demonstrated values and commitment to deliver high-quality sustainable services. However, the ineffective assessment and mitigation of risk and lack of robust oversight impacted the day-to-day management of the service.

Systems and processes were not always embedded, and the inspection highlighted some issues and omissions in relation to governance processes.

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

There were ineffective processes for identifying and managing risks and performance. We identified concerns around the management of risks associated with fire and the use of hazardous substances. Existing risk assessments were not suitable to identify, assess and mitigate risks at the service, as they did not accurately reflect what happened at the practice. For example, the Sharps risk assessment dated 8 January 2025 stated that “all team members are vaccinated against Hepatitis B and records of titre levels are kept in their staff folders” and the Health and Safety risk assessment of the same date stated that “COSHH assessments are available”. These statements were not consistent with our inspection findings.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.However, improvements could be made to ensure audits effectively identified areas for improvement and were used to drive meaningful changes in practice.

Staff told us that complaints would be acknowledged and investigated in a timely manner and outcomes discussed to share learning for development. The complaint procedure was not displayed at the practice on the day of inspection. Improvements were needed to ensure information and guidance about how to make a complaint were available and accessible to all patients who used the service.

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

The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. However, some policies contained incorrect information or were not specific to the service. This included the Closed Circuit Television (CCTV) policy. In addition, we noted that not all cameras located at the reception did not have the appropriate signage. Following the inspection the provider submitted photographic evidence confirming that signage to indicate the presence of cameras had been displayed, the CCTV policy had been updated, and a Privacy Impact Assessment had been completed.

Staff password protected patients’ electronic care records. However, we observed that some paper records were stored in a transparent plastic box at the reception, in an area visible to patients. In response to our feedback the provider told us that these paper records had been moved to a secure storage to protect patient privacy.

Staff feedback was obtained 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 practice gathered Friends and Family Test feedback from patients. While the practice encouraged patients to leave online feedback, improvements were needed to ensure a more inclusive and structured approach to gathering patient views. This includes introducing a formal patient satisfaction survey that accommodates all patients, including those without internet access, and implementing regular analysis of feedback to identify trends and areas for improvement, thereby supporting a culture of continuous service development.

The practice had taken steps to improve environmental sustainability. For example, they segregated waste and used digital records which reduced waste.

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.