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

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 a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Systems and processes were embedded, and the inspection did not highlight any significant issues or omissions. Minor areas requiring improvement were acted on immediately.

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.

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

The practice should implement an effective system for recording, investigating and reviewing incidents and significant events with a view to preventing further occurrences and ensuring that improvements are made as a result. We reviewed 2 needlestick injuries where there was inconsistent evidence of investigation or learning to prevent reoccurrence.

We also reviewed 3 patient safety incidents. Patient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for patients receiving care. We found these were dealt with in line with the Duty of Candour. However, there was a lack of oversight and root cause analysis to identify any trends or lessons for the purpose of learning and improving patient safety. We discussed this with the provider who confirmed this would be actioned.

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 had clear responsibilities, and systems of accountability to support good governance.

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. In a recent patient survey, some patients had commented they were not aware of the practice complaints procedure. In response, the procedure was displayed more clearly in the waiting area and staff received training to ensure they were aware of the process to follow. Patients were also encouraged to complete the NHS friends and family survey. In October 2025, there were 14 responses of which 13 rated the service as good or very good.

The practice had taken steps to improve environmental sustainability. For example, by recycling where possible and using digital systems to reduce paper.

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.