Peelhouse Dental Care

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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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.

The practice staff demonstrated a transparent and open culture in relation to people’s safety.

Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management.

Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

Staff told us how they collected and responded to feedback from patients, the public and external partners.

The practice had taken steps to improve environmental sustainability. For example, recycling and car sharing where possible and the whole team had decided to use reusable containers for lunch instead of using disposable packaging.

Systems and processes were embedded, and staff worked together in such a way that where the assessment identified areas requiring improvement, these were acted on immediately.

The practice had governance systems which included policies, protocols and procedures. These were easily accessible to staff, and most were reviewed regularly. However, some governance systems were not working effectively and did not always support leaders to maintain full oversight of the service.

There were processes for identifying and managing risks, issues and performance. However, these were not always working effectively. Managers did not always have oversight of completed staff training, and some systems and processes were not consistently followed. Some risks were not always managed appropriately, for example, risks relating to employment, sharps, fire, and radiation.



The practice’s systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts were not clear or well documented. There was no evidence the practice had an incident and accident reporting policy and follow-up actions were not documented. The practice did not have systems for receiving and acting on patient safety alerts, recalls and rapid response reports. The practice acted immediately and submitted evidence following the assessment that systems had been implemented.

The practice had systems to respond to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

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).

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV). However, a Data Protection Impact Assessment (DPIA) had not been carried out to assess the purpose, necessity, and risks prior to installation of CCTV. Following the on-site assessment, the practice sent evidence that a DPIA had since been completed.

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.