Dental Surgery - Main Street Billinge Also known as Saxon 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 not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider.

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 identified some issues and omissions in relation to governance arrangements. The provider acted immediately to reduce the risk of some of these issues. The improvements implemented will be reviewed at a follow-up inspection to ensure systems and processes are embedded. The practice’s systems and processes for managing and maintaining oversight of risks and issues were not always clear and effective. In particular, the risks associated with health and safety, substances hazardous to health, fire safety and the management of Legionella.

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.However, we noted the clinical record and radiography audits did not identify or reflect the issues we found with the clinical records and the inconsistent recording of consent processes. We discussed this with the provider who assured us this would be rectified to ensure they effectively identify areas for improvement.

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 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 practice had taken steps to improve environmental sustainability. For example, the practice recycled all cardboard, 1 light was on a sensor and staff turned off lights and electronics 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.