Cleveland Terrace 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 always providing well-led care in accordance with one of 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 some systems or processes in place that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate some of the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, certain aspects of the safe and effective recruitment of staff, and other risks related to undertaking of regulated activities such as fire safety, management of medicines and recruitment. 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 quality statement 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 there was a lack of leadership and oversight to assess, monitor and improve certain aspects of the quality and safety of services provided, which led to the issues highlighted by the on-site assessment. Staff needed clarity on their responsibilities, roles and systems of accountability to support good governance and management. However, we found staff to be open to discussion and feedback to make the necessary improvements to ensure people’s safety. Feedback from staff was obtained through informal discussions. Staff stated they felt respected and valued and were proud to work in the practice. Staff told us how they collected and responded to feedback from patients, the public and external partners.

Systems and processes were not always embedded and the assessment highlighted some issues and omissions. However, staff worked together in such a way that where the assessment identified areas that required improvement, many were acted on immediately. Certain aspects of the information and evidence presented during the assessment were not clear nor well documented. Processes for identifying and managing certain risks, issues and performance were sometimes unclear and ineffective. This included risks associated with fire. The governance system including policies, protocols and procedures was not always effective or reviewed regularly. Staff files were incomplete. Examples of the required documents missing included Disclosure and Barring Service certificates, indemnity certificates and continuing professional development certificates. References were not consistently sought at the point of recruitment. The practice had ineffective systems and processes for certain aspects of learning, quality assurance and improvement. Audits were not always undertaken according to recognised guidance. Record keeping and infection prevention and control audits were not completed. Radiography and disability access audits were insufficient and incomplete. There were no actions or evidence of shared learning. The practice had systems to review and investigate incidents and accidents. However, we saw evidence of a recent sharps injury that was not dealt with in line with occupational health guidance. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV). However, there was insufficient signage to alert the public. The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. They complied with General Data Protection Regulations. The practice had effective processes for receiving and acting on safety alerts. The practice responded to complaints appropriately.

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.