Cleggs Lane Dental Practice

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 ineffective systems or processes that failed to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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. the registered person had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office. 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 evidence category 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.

The inspection highlighted some issues and omissions. Most areas requiring improvement were acted on immediately and we have asked the provider for an action plan in response to the concerns found at this assessment. Although policies and procedures were accessible to staff, the governance and management arrangements in place were not always effective. In particular, a number of policies were generic and had not been updated to reflect the practice protocols, and oversight systems for monitoring staff training completion had not identified overdue training for some staff. The practice’s systems and processes for managing and having oversight of risks and issues were not always clear and effective. For example, displayed information on the process for sharps injuries was out-of-date, staff did not have access to COSHH safety data sheets, and the fire alarm service and emergency lighting service were overdue. Staff had not been carrying out or recording checks of water temperature to manage the risk of Legionella. The medical emergency kit checks had not been carried out weekly in line with national guidance, which meant staff had not identified multiple items missing from the medical emergency kit. There was no log to monitor the use of, or identify misuse, loss or theft of NHS prescription pads. The autoclave data logger had not been accessed for over 7 years, which meant the provider did not have assurance or oversight of its effectiveness. The practice had not completed a Data Protection Impact Assessment (DPIA) and did not have a Closed-Circuit Television (CCTV) policy. The practice manager completed the DPIA and created a CCTV policy on 30 January 2025.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We noted the radiography audit was not always completed as frequently as guidance requires. We discussed this with the provider who assured us this would be rectified. 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. There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts. Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. We noted innovative approaches to providing person centred care. Staff demonstrated an open culture in relation to people’s safety. Staff had clear responsibilities, and systems of accountability to support good governance. Staff feedback was obtained through meetings, surveys, 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. Feedback from patients, the public and external partners was collected to which the practice responded. The practice had taken steps to improve environmental sustainability. For example, sensor lights were in most rooms and they only turned on when entering a room, the practice was working towards being paperless. The recycled all paper and cardboard and 1 member of staff had an electric car.

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.