Hindley 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 has made the required improvements.

During our assessment of this key question, we found:

Systems and 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 were not effective.

Systems and processes to assess, monitor and improve the quality and safety of the services being provided were not effective.

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 report 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.

Improvements were required to some of the practice’s systems and processes to improve management oversight. The on-site inspection highlighted some issues and omissions. The provider acted immediately to reduce the risk of some of these issues.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. Improvements were required to ensure these were updated in line with current legislation or nationally recognised guidance and reflective of practice protocols.

We noted improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, risks associated with fire, health and safety, stock control and sharps safety.

The practice had ineffective systems for receiving and acting on patient safety alerts, recalls and rapid response reports.

The practice had ineffective systems to review and investigate incidents and accidents. In particular, there was no evidence the practice had an incident and accident reporting policy, and not all incidents and accidents were documented appropriately with follow-up actions recorded and evidence of reflection and shared learning.

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.

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.

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, the practice had increased some appointment times following staff feedback.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, the practice had changed the way they update patients’ medical histories following staff feedback.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible and turned electrical devices and lights off when not in use.

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.