Thorley 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 providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider has made the required improvements.

We also found ineffective systems or processes that failed to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, regarding management of fire safety, electrical safety, cleaning of the premises, IPC, recruitment of staff, oversight of staff training, management of COSHH and the management of medical emergency equipment and medicines.

We also found that there were not effective systems to ensure dental records were stored securely.

This resulted in a breach of Regulation 17: Good Governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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.

Feedback from staff was obtained through informal discussions as no formal practice meetings were held. However, due to the small size of the practice staff, regular conversations were taking place and information was easily shared.

Staff stated they felt respected, supported and valued. They were proud to work in the practice. We found staff to be open to discussion and feedback.

Staff told us how they collected feedback from patients with the use of a suggestions box in the waiting area.

Clinical paper records were not stored securely. Following the inspection, we saw that the practice had enquired about having bespoke lockable filing cabinets made.

We found staff to be open to discussion and feedback. However, improvements were needed to the oversight of the practice to ensure that it was consistently safe and well-led for patients and staff.

We saw the processes in place were not effective for identifying and managing all risks, issues and performance, in particular regarding the management of fire safety, electrical safety, IPC, recruitment, continuing professional development, medical emergencies and the management of COSHH.

The practice responded to concerns and complaints appropriately. However, no complaints information was on display for patients in the practice, or on the website. Following the inspection, we saw that information was now on display for patients.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. Mandatory audits were being carried out, yet the IPC audit was not reflective of practice procedures.

Following the inspection, the practice was very responsive and appeared keen to learn and improve, and to comply with regulations.

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.