Ledbury Dental 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. We will be following up on our concerns to ensure the provider had made the required improvements.

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. There was also 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 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Systems and processes to support effective governance and oversight were not embedded.



Not all staff were aware of the importance of protecting patients’ personal information. Paper records were not stored securely in line with General Data Protection Regulations.

There were effective processes for investigating incidents and accidents and for receiving and acting on safety alerts.

Systems and processes for learning, quality assurance and continuous improvement needed strengthening. The infection control and clinical record audits did not identify the issues we found. Radiography audits needed to be competed 6 monthly rather than annually and antimicrobial prescribing audits were not carried out according to recognised guidance. A disability access audit had not been completed. We have since been provided with a clinical governance report prepared annually by the practice manager for the registered person.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. The provider had not taken steps to ensure patients were encouraged and understood how to make a complaint. We discussed the benefits of displaying their complaints procedure in the waiting room.

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.

Although there had been no complaints and patient feedback, feedback from patients, was not actively sought by the provider to drive quality improvements and help identify areas needing attention.

The practice had taken steps to improve environmental sustainability.

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.