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.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 14 November 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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.

During the inspection on 14 November 2025, we found that the responsible person did not understand 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. During the follow-up inspection on 13 February 2026, we were unable to obtain assurance that the responsible person had developed a sufficient understanding of their regulatory responsibilities or that governance and compliance arrangements had been strengthened, were effective and embedded within the practice.

Although the provider submitted a detailed action plan dated 19 November 2025, which outlined the actions proposed to address the concerns identified and included clear timescales for completion, there was no evidence at the follow-up inspection on 13 February 2026 that these actions had been completed or embedded into practice. This lack of demonstrable progress raised further concerns regarding the provider’s capability and capacity to effectively support the service in achieving compliance with relevant legislation and regulatory requirements.

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

During the follow-up inspection on 13 February 2026, staff told us that to their knowledge, the only 2 folders currently in active use were the clinical waste consignment notes folder and the fridge/ water temperatures log folder. Staff further told us that all other folders observed on the floor in Surgery 1 contained historical documents and otherwise were no longer in use. We were not assured that there were effective systems in place to ensure staff had access to up-to-date policies, procedures and guidance to support them in carrying out their day-to-day responsibilities.

During the inspection on 14 November 2025, we found that 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. During the follow up inspection on 13 February 2026, we were unable to obtain assurance that robust risk management systems had been implemented or embedded to identify, monitor, and mitigate these risks, or that previously identified risks had been effectively addressed to ensure the safety of patients and staff.

During the inspection on 14 November 2025, we found that 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. A revised health and safety risk assessment was not available for review during the follow up inspection on 13 February 2026 to demonstrate that risk to staff and patients had now been suitably identified and assessed to ensure there were suitable control measures in place.

During the inspection on 14 November 2025, we found that there were ineffective processes for receiving and acting on safety alerts. The provider 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). During the follow-up inspection on 13 February 2026, staff indicated that only two folders were in active use. These folders did not contain information or evidence to demonstrate that improvements had been made in relation to monitoring or acting on recalls, safety alerts, or rapid response reports.

During the inspection on 14 November 2025, we found that 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. During the follow-up inspection on 13 February 2026, we were unable to obtain assurance that a robust and effective complaints management system had been implemented to ensure that concerns raised by patients were appropriately recorded, investigated, and acted upon.

During the inspection on 14 November 2025, we found that there were ineffective systems in place for regular auditing of the service to drive continuous improvement. In the absence of an effective audit program, the provider was unable to identify areas for improvement and take prompt action to improve the quality, effectiveness, and safety of the service. During the follow-up inspection on 13 February 2026, we were unable to obtain assurance that effective auditing systems had been implemented and embedded to monitor service quality, identify risks, and drive improvements across clinical and non-clinical areas of the practice.

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.