Love the Dentist Mobberley

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:

Systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk were not effective.

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.

Improvements were required to some of the practice’s systems and processes to improve management oversight. The on-site inspection highlighted some issues and omissions. The provider acted immediately to reduce the risk of some of these issues.

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

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.Improvements could be made to ensure the radiography audit was in line with national guidance. In particular, the sample size and ensuring there is an action plan to drive improvement.

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. We highlighted that the computer screen in the reception area was visible to patients and visitors. The practice acted immediately and sent evidence following the inspection that a privacy screen had been implemented.

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

The practice had processes to investigate and respond to complaints and to share learning for improvement.

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. For example, the practice had made changes to software for new patient lead tracking, had purchased new equipment and had altered appointment lengths following staff feedback.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, the patient had included a link to their patient portal on their website for ease of accessibility following patient feedback.

The practice had taken steps to improve environmental sustainability. For example, the practice had swapped to paper cups to reduce single use plastic, recycled where possible and had installed sensor lights to save energy.

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.