Synergy Dental Clinic Liverpool Ltd

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 they have been put right by the provider.

During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the ineffectiveness of the 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 body of the report 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.

Feedback from staff and leaders

We found staff to be open to discussion and feedback.

The practice staff demonstrated a transparent and open culture in relation to people’s safety.

Staff told us they had clear responsibilities, roles and systems of accountability to support the management of the practice.

Feedback from staff was obtained through meetings, surveys, and informal discussions.

We saw the group had processes to develop staff with additional roles and responsibilities and staff told us they liked working at the practice.

Staff told us how they collected and responded to feedback from patients.

The practice’s information governance arrangements ensured all patients’ electronic care records were password protected and that paper records were stored securely to comply with General Data Protection Regulations (GDPR).

The practice’s policies, protocols and procedures were accessible to all members of staff.

The assessment highlighted areas where improvements were needed, such as risk management and adherence to protocols.



Improvements should be made to the oversight of the leadership team to ensure that the practice’s clinical governance systems and processes are followed and risks managed appropriately.

Improvements were needed to ensure processes for managing risks were effective. The practice did not have adequate systems in place for identifying, assessing and mitigating risks in areas such as the completion of risk assessments, recruitment, staff training and legionella.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Improvements were needed to ensure audits were undertaken at the relevant intervals in accordance with current guidance, for example, infection prevention and control audits were not completed every 6 months.

The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. We were told action had been taken following accidents and incidents; however, we could not see any record of this. From the record available, we found limited evidence that an accident was appropriately recorded, reported and reviewed to use it as an opportunity for shared learning.

However, the information and evidence presented during the inspection process was clear and well documented.

Staff were aware of the importance of protecting patients’ personal information.

The practice should improve the practice's complaints handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users. From the information recorded, we could not be assured all complaints were managed in accordance with the practice protocols.

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.