Cleveland Terrace 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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breach we found at our assessment on 24 September 2024.

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.

At the assessment on 17 February 2025, we found the practice had made the following improvements to comply with the regulation:

We found improvements to leadership and oversight to assess, monitor and improve the quality and safety of services provided.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises.

Staff had clarity on their responsibilities, roles and systems of accountability to support good governance and management.

Staff told us of processes put in place to ensure procedures and policies were reviewed on a regular basis.

Improvements had been made to antimicrobial dispensing and the practice ensured that patient information leaflets were given out with each prescription. Improvements had also been made to the antimicrobial log which would highlight if antibiotics went missing.

We saw evidence that systems and processes had been improved and were starting to be embedded.

The information and evidence presented during the assessment was clear and well documented.

Processes for identifying and managing risks, issues and performance were clear and effective. This included the risks associated with fire, lone working and sharps injuries.

A fire risk assessment had been completed by an external, competent person on 25 September 2024 which identified a number of recommendations. The practice provided evidence on 17 February 2025 that they had all been actioned.

We saw evidence of internal checks of fire equipment such as alarms, extinguishers and emergency lighting.

We were provided with an updated gas safety record, showing this was completed in September 2024.

Staff files were now complete. All documents were in each file with an index to ensure nothing was missed. We were assured that the practice would request and document the required information for future recruitment. We saw induction checklists that covered safeguarding for new staff members. Continuing professional development certificates for each staff member were stored in a clear and consistent manner.

The practice had completed audits for learning, quality assurance and continuous improvement. Record keeping, infection prevention and control audits, radiography, antimicrobial and disability access audits had been completed. We saw evidence of actions and shared learning.

Improvements had been made to signage alerting members of the public of the CCTV) Closed-Circuit Television cameras. This included increasing the number and improving the location of the CCTV signs.

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.