Great Cornard 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 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 them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the ineffectiveness of the systems or processes for the recruitment, training, support and development of staff and 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 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.

The provider had taken ownership of this practice in 2023 and had a relatively new team in place. We found staff to be open to discussion and feedback. The practice had recently sought external compliance support. We noted systems and processes had been introduced to support the practice governance, management and sustainability as a result of this support. However, there was scope for these systems and processes to become embedded within the practice to achieve these systems of accountability and good governance.

Feedback from staff was obtained through informal discussions. Staff told us they were encouraged to offer suggestions for improvements to the service and they said these were listened to, where appropriate. However, staff meetings, staff inductions and staff appraisals were not undertaken, we discussed this with the provider who confirmed these would be put in place.

Staff stated they felt respected, supported and valued. They were proud to work in the practice. There was scope to ensure processes to support and develop staff with additional roles and responsibilities were in place and embedded within the practice team.

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

The practice responded to concerns and complaints appropriately. There was scope to ensure outcomes were discussed and shared with staff to ensure learning and improve the service.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information.

Systems and processes to support effective governance and oversight were not embedded.

Where the assessment identified areas which required improvement, some of these were acted on immediately and the provider and staff demonstrated a commitment to addressing all issues identified. The information and evidence presented during the assessment was not always clear and well documented.

The practice had a governance system which included policies, protocols and procedures. We found that these were not stored in a way that made them easily accessible to all members of staff. There was scope to ensure these policies were reviewed annually, were accessible to all staff and were seen and signed once read by all staff.



Staff password protected patients’ electronic care records and paper records were stored securely and complied with General Data Protection Regulations (GDPR).

Processes for identifying and mitigating risks, issues and performance were not always clear and effective. A legionella risk assessment was scheduled to be undertaken in February 2025, there was no risk assessment in place for Health and Safety at the practice and no risk assessments for those staff who had not completed a full course of hepatitis B vaccinations or had a record of confirmed immunity. There was scope to ensure the sharps risk assessment reflected the processes used in the practice and was in line with current guidelines. There was scope to improve and embed the practice systems to review and investigate incidents and accidents and for receiving and acting on safety alerts.

The practice systems and processes for learning, quality assurance and continuous improvement were not established or effective. Audits of infection prevention and control, radiography, disability access, record keeping and antimicrobial prescribing were not carried out. Radiography equipment was not always maintained in line with manufacturers guidance.

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.