Coronation Road 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.

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 provider’s oversight of regulatory requirements required improvement.

Systems and processes were not embedded among staff which highlighted a number of issues which included, recruitment, training, control of substances hazardous to health, emergency medicines, radiography equipment maintenance, infection prevention and control and fire safety management.

A health and safety risk assessment had not been carried out.

There were effective processes for identifying and managing incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes for learning, quality assurance but improvement was needed to ensure infection prevention and control audits and antimicrobial audits were carried out at the recommended intervals.

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

The storage of completed staff recruitment, accident and complaint records did not comply with General Data Protection Regulation requirements.

Staff feedback was obtained through informal discussions.

We were shown records to confirm staff meetings took place in November 2025 and May 2025. The practice was unable to demonstrate that other meetings had taken place.

The practice gathered feedback from patients and responded accordingly.

The practice had taken steps to improve environmental sustainability. Waste was segregated to identify what can be recycled and paper was kept to a minimum. A bicycle rack was available for staff who wished to cycle to work.

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.