JH Dental Clinic

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 the provider had made the required improvements.

During our assessment of this key question, we found lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of 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 Regulations 12 and 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.

Systems and processes to support effective governance and oversight were not embedded. Where the assessment identified areas which required improvement the provider was responsive to ensure that some of these issues were acted on.



There was scope for improvement to the practice’s governance system. During the assessment, information and evidence was not always available. We also noted that staff were not working in accordance with some of the practice policies, for example the recruitment policy. We found that policies were not always effective in ensuring governance, oversight and risk mitigation tasks were completed in line with guidance.

Recruitment files were available on the premises; however, the provider was not working in accordance with their recruitment policy as not all of the required pre-employment information was available for all staff.

Oversight of some procedures for example, recruitment and completion of staff training were not effective.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information. Paper records were stored securely and complied with General Data Protection Regulations (GDPR).

We saw there were processes for identifying and managing some risks, although there was no fire or legionella risk assessments. A fire risk assessment was booked for 13 March 2025. There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

The provider confirmed that they had not received any formal complaints within the past 4 years. We were told that staff would discuss outcomes to share learning and improve the service as needed.

There was scope for improvement with the practice’s systems and processes for learning, quality assurance and continuous improvement.

Staff feedback was obtained through informal discussions. There was no system of formalised practice meetings or staff appraisal.

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.