Yorkshire Dental Suite York

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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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 were embedded, and the assessment did not highlight any significant issues or omissions.

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.

The practice had closed-circuit television cameras (CCTV). However, they had not completed a Data Protection Impact Assessment. We raised this with staff and were assured one would be completed.

The practice had a governance system that included policies and procedures, some of which were accessible to staff and were reviewed on a regular basis. Staff did not always have clear responsibilities, and systems of accountability to support good governance. Clarity around management roles, particularly creating and reviewing policies, could be improved.



There were some effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts. However, the practice should take action to implement recommendations from their fire safety risk assessment. We saw a fire risk assessment that had been completed by a competent person in October 2024, had multiple recommendations none of which had been actioned.

Water temperatures were being tested at the required intervals. However, the accessible toilet temperature had been lower than required for a prolonged period and this had not been raised with management. We raised this with staff and were assured it would be addressed.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, the practice should take action to ensure audits are undertaken at regular intervals to improve the quality of the service. The infection, prevention and control (IPC) audit had not been completed at the required 6-monthly interval. A radiography audit had not been completed. We discussed this with the compliance manager and practice manager and were told a new IPC audit would be carried out and a process for radiography audits was in progress.

Staff feedback was obtained through meetings, surveys, and informal discussions. Management held monthly support calls with clinicians. Staff reported they were actively encouraged with further education and qualifications.

Feedback from patients, the public and external partners was collected to which the practice responded. For example, patient feedback is requested after every appointment and the practice had a dedicated team to review and respond to them.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

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.