Ilkley Dental Care Limited

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 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.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. However, these were not always followed. In particular, recruitment.



There was a lack of governance and oversight to identify and manage risks. In particular, ensuring effective checks of medical emergency equipment, assessing the risk from sharps, ensuring adequate immunity for vaccine preventable diseases, and ensuring appropriate reports were easily accessible, with records of actions taken in a timely way.

Areas requiring improvement were acted on immediately. However, newly implemented systems were not yet embedded.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We highlighted radiographic audits could be improved by including a retrospective analysis with conclusions and action plans. We signposted them to resources to support this process.

There were systems 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.

Staff feedback was obtained through meetings, a secure online discussion platform 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. For example, the manager produced patient survey reports to share with the team.

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 taken steps to improve environmental sustainability. For example, through responsible waste management and energy-saving measures. Digital record-keeping was encouraged to minimize paper usage, and they practice recycled batteries, toothbrushes and interdental brushes.

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.