Space Dental Sheffield

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.

At the time of the inspection, there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered. After the inspection the provider confirmed this was in the process of being addressed.

During our inspection of this key question, we found:

The registered person had ineffective systems or processes to enable them 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.

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 practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, some policies and procedures were not embedded resulting inconsistently following agreed processes.

Processes for identifying and managing risks were ineffective. The practice did not have effective systems to identify and manage risks for radiation and laser protection, fire safety, Legionella and hazardous waste until they were highlighted by the inspection. After the inspection the provider was given the opportunity to send in further evidence. However, the documentation submitted did not provide complete assurance in these areas. Changes to improve systems and processes are not yet embedded, and these will be reviewed at a follow-up visit.

We reviewed a recent sharps injury and found the practice did not follow their policy for investigating incidents and accidents. There was no evidence of the advice obtained and whether this was followed within the documentation we reviewed.

We were not assured there was a current system for receiving and acting on safety alerts. We asked for evidence to be sent after the inspection but the alert we were sent was dated 2022, and no evidence was sent regarding the process.

Staff told us they undertook audits according to recognised guidance. However, the most recent documented infection prevention and control audit was dated 30 April 2025 and was partially completed. The last documented radiographic quality audit was dated July 2022 and there was no evidence of analysis, conclusions or an action plan. These audits should be carried out on a six-monthly basis. Evidence of radiographic quality audits carried out after the inspection were later submitted.

Staff feedback was obtained through daily huddles, meetings and informal discussions. Staff did not always feel respected, valued or supported in their roles, and a lack of communication about recent leadership changes was highlighted during the inspection process.

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.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

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

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, using digital systems.

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.