Dale Road Dental Clinic Also known as South Cliff Dental Group Shirley Dale

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 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 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.

We found staff to be open to discussion and feedback. Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service. Staff told us how they collected and responded to feedback from patients, the public and external partners. The team told us they had a system to report incidents and accidents. However, staff were unsure of how this system worked and were unable to demonstrate to us how an incident would be reported using this system.

There was a lack of leadership and oversight at the practice and systems and processes were not embedded among staff. There had recently been a high turnover of staff, and most had been in position for less than 6 months. The information and evidence presented during the assessment was not always clear and readily available. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. However, as many staff were new, they were not familiar with the governance systems in place. The practice did not have clear and effective processes for managing risks, issues and performance. For example, the risks associated with fire, hazardous substances, the use of sharp instruments and the oversight of the maintenance of equipment. The practice had a system to respond to complaints. We were told that complaints were dealt with at practice level and patients were provided with the practice email address for this. At the time of assessment the practice manager did not have access to the email address. In addition, we saw evidence of refunds provided to patients and no evidence of any complaint. We discussed this with staff and were told the complaints process would be reviewed to ensure effective oversight of this. The practice had information governance arrangements and 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 (GDPR). The practice had a system for receiving and acting on safety alerts. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. However, these quality assurance processes did not identify the issues we identified on the day of inspection.

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.