Clough Dental Surgery

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 mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

In addition, we found the registered person did not maintain records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activity. In particular, relating to staff recruitment and staff training.

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 policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, systems and processes were not fully embedded to ensure good governance and effective management of risk.

Improvements were required to the systems and processes for managing the risks associated with the carrying on of the regulated activities. In particular, the risks associated with the use of radiation, Legionella, the oversight of equipment maintenance and the management of medical emergency equipment and medicines. In addition, improvements were required to the monitoring of staff training and recruitment processes to ensure they complied with legislation.

Improvements were required to the systems and processes for learning, quality assurance and continuous improvement. Although some audits had been carried out these were either incomplete, not completed at the required timescale or had not identified issues we found on the day of inspection. In addition, the system for monitoring staff training was not working effectively as there was limited evidence staff had completed required training.

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.

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

Staff feedback was obtained through meetings 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 feedback from patients, the public and external partners, and responded accordingly.

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.