Claremont Dental Surgery - Wigan

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 systems or processes that operated ineffectively in that they failed to enable the registered person to assess, monitor and improve the quality and safety of the services being provided. the registered person had systems or processes that operated ineffectively in that they 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. 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 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.

During the inspection 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. Feedback from staff was obtained through informal discussions. Practice meetings and appraisals were not routinely conducted. We were advised that these would be implemented. The practice had taken steps to improve environmental sustainability. For example, staff were encouraged to cycle to work.

Improvement could be made to the management oversight for some of the practice’s systems and processes and the assessment highlighted some issues and omissions. We noted improvements could be made to the oversight and support of the leadership team to ensure that the practice’s systems and processes were followed, and risks managed appropriately. The practice had a governance system which included policies, protocols and procedures that were accessible to members of staff. However, we noted some policies lacked detail, such as the recruitment and consent policies. Improvements could be made to the processes for identifying and managing risks, issues, and performance. In particular the risks associated with fire, legionella and gas safety. Improvements could be made to the systems to review and investigate incidents and accidents. There were no records for any significant events or near misses. We discussed what staff considered to be a significant event. We were assured this would be addressed and rectified. The practice had systems for receiving and acting on safety alerts. The practice had procedures to respond to concerns and complaints appropriately. Improvements could be made to the systems and processes for learning, quality assurance and continuous improvement. The practice conducted audits of clinical records, radiography, infection prevention and control and reasonable adjustments. However, we noted the radiography had not been completed since October 2022 and did not have an action plan to drive improvement. In addition, there were no action plans for the clinical record keeping and reasonable adjustment audits. The practice did not carry out antimicrobial prescribing audits.

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.