Archived: Pennine Dental and Medical Care

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.

During our assessment of this key question, we found

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided and

a lack of systems or 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.

This resulted in a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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.

We were not assured that the responsible person understood their roles and responsibilities to support good governance and management. They were not always aware of the legal requirements or the compliance arrangements within the practice.

The information and evidence presented during the inspection was not clear or well documented.

There were ineffective processes for identifying and managing risks. We identified concerns regarding the management of risks associated with fire, Legionella, Infection Prevention and Control (IPC), radiation safety, control of substances hazardous to health, medical emergencies, and safe staffing.

The practice general health and safety risk assessment dated 23 April 2025 did not suitably identify and assess risks. It stated that the autoclave was serviced every 12 months, caution signage was displayed on radiators, the compressor was serviced every 26 months, staff were trained in fire evacuations procedures, firefighting equipment was checked and tested annually, access to fire exits were kept clear, an RPA was appointed, and X-Ray equipment was regularly checked and maintained. However, none of these statements were substantiated by our findings.

There were ineffective processes for receiving and acting on safety alerts. The practice principal was not aware of any relevant Patient Safety Alerts, recalls and Rapid Response Reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).

The practice did not have systems and processes for learning, quality assurance and continuous improvement.

The complaints procedure was not displayed in the waiting room or on the practice website. The practice principal told us the practice had received multiple complaints. The provider could not demonstrate that complaints had been formally recorded, and a structured complaints process had been followed.

There were ineffective systems in place for regular auditing of the service to drive continuous improvement. A radiography audit dated 25 May 2025 did not include a representative sample in line with relevant guidance. Additionally, there were no comments, action plans, or evidence of shared learning, and no previous audits were available for review. Similarly, the infection prevention and control audit dated 29 August 2025 was not reflective of our findings on the day and previous audits were not available.

In the absence of an effective audit program, the provider was unable to identify areas of improvement and take prompt action to improve the quality, effectiveness, and safety of the service.

The practice started gathering feedback from patients following the announcement of the inspection. However, there were no systems in place to analyse this feedback for themes and trends in order to drive continuous improvement.

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.

However, relevant policies and protocols for the use of closed-circuit television (CCTV) were not in place. The practice had not completed a Data Protection Impact Assessment, and appropriate signage was not dispalyed to inform service users of the presence of CCTV cameras.

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.