Church 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 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. 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 complied with General Data Protection Regulations.

There were effective processes for identifying and managing risks, investigating accidents, and for receiving and acting on safety alerts. We noted improvements should be made to the systems to review, investigate and document incidents. In particular, ensuring all incidents are documented including evidence of reflection and shared learning.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits. However, we noted the radiography audits were not consistently carried out every 6 months in line with national guidance and had no action plan to drive improvement. We discussed this with staff and were assured it would be addressed.

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.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, the practice had staggered lunch breaks to allow more availability to the downstairs surgeries for patients with limited mobility.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled and turned electrical devices and lights off 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.