Mark Kent 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 improve the quality and safety of the services being provided and

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.

These concerns were in 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 staff to be open to discussion and feedback. Where the assessment highlighted issues, the practice took some action to address these concerns t the time of the inspection.

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

We found that the provider demonstrated appropriate values and a commitment to delivering high‑quality, sustainable services, however, this was not consistently supported by effective systems and processes. Ineffective risk management arrangements and a lack of robust oversight had an impact on the day‑to‑day management of the service.

The general risk assessment dated 16 January 2026 was not suitable to assess and mitigate risks within the practice. It includes a number of standard statements, such as fire alarm testing, display of fire action notices, clearly marked fire exits, consideration of emergency lighting, bi-annual fire drills, COSHH coverage for hazardous substances (under a separate assessment), and the use of safer sharps with devices for re-sheathing needles. However, these statements were not substantiated by our findings. As such, the document did not accurately reflect the current risk controls in place.

The Infection Prevention and Control required update to accurately reflect the decontamination processes in place and to ensure alignment with national guidance.

We also identified shortcomings in the management of risks associated with fire, the use of sharps, COSHH and infection prevention and control.

Staff were aware of the importance of protecting patients’ personal information. Paper records were stored securely in lockable cabinets.

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

There were systems in place for investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems and processes for quality assurance and continuous improvement. This included undertaking audits according to recognised guidance in line with recognised guidance. Improvements could be made to ensure that audits were sufficiently robust to identify gaps in processes, including those relating to record keeping and infection prevention and control. In addition, further improvements were required to ensure that continuous learning was effectively supported through robust monitoring of training and regular appraisal of individual development needs.

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.

The practice gathered informal feedback from patients. However, there was limited evidence of structured, formal patient satisfaction surveys being undertaken. To strengthen governance and quality improvement processes, the practice could benefit from implementing regular surveys and systematically analysing responses to identify themes and trends, supporting continuous service improvement.

The practice had taken steps to improve environmental sustainability. They ensured correct waste segregation and used eco-friendly lighting.

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.