The Wrekenton 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.

During our assessment of this key question, we found:

The registered person had ineffective 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 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 detailed 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.

The inspection highlighted some issues and omissions. On the day of the inspection staff were open to feedback and took immediate actions to address some of the concerns raised during the inspection. They demonstrated a commitment to continuing the work and engagement with staff and external organisations to make further improvements.



The practice’s systems and processes for managing and having oversight of risks were not always clear and effective. For example, the system for checking the medical emergency kit was not working effectively, which resulted in multiple expired items not being identified.

Risk assessments needed to be updated for fire, hazardous substances, sharps and general health and safety.

There was no oversight or system in place to amend and update policies with the most up-to-date information and there was no recruitment policy available. However, the practice did have all relevant checks in line with Schedule 3 guidance.

We were assured that all policies would be updated to include current guidance and legislation and continually reviewed moving forward.

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.

The practice had systems and processes for learning, quality assurance and continuous improvement. Although the practice was completing audits these had not identified the issues we found on the day of assessment. We discussed the importance of having a robust quality assurance process to support good governance in the long term.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff demonstrated an open culture in relation to people’s safety. Staff had clear responsibilities.

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

The practice had taken steps to improve environmental sustainability. For example, lights and equipment are switched off when not in use, the practice also recycled where they could.

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.