• Dentist
  • Dentist

Cavendish Dental Practice

13-15 Derby Lane, Cavendish, Derby, Derbyshire, DE23 8UB (01332) 764997

Provided and run by:
Dr. Trishan Malhi

Report from 28 May 2024 assessment

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Well-led

Regulations met

Updated 11 June 2024

We found this practice was providing well led care in accordance with the relevant regulations and had taken into consideration appropriate guidance. The provider had made improvements in relation to the regulatory breach we found at our inspection on 20 September 2023

Find out what we look at when we assess this area in our information about our new Single assessment framework.

Shared direction and culture

Regulations met

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

Capable, compassionate and inclusive leaders

Regulations met

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

Freedom to speak up

Regulations met

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

Workforce equality, diversity and inclusion

Regulations met

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Governance, management and sustainability

Regulations met

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises. At the assessment on 5 June 2024, we found the practice had made the following improvements to comply with the regulation: The practice had made the following improvements. Effective systems were in place 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. The management of fire safety was effective. Risk assessments were in place and required monitoring checks of the safe operation and availability of fire detection equipment and exits was in place. The provider had developed guidance and bespoke recording systems as well as ensuring that all staff had received training o enable them to complete these tasks and take action where required. The management of legionella risk was effective. Risk assessments were in place and required monitoring of checks to reduce the risk and spread of water borne bacteria were in place. The provider had developed guidance and bespoke recording systems as well as ensuring that all staff had received training o enable them to complete these tasks and take action where required.

The practice had also made further improvements. Decontamination processes followed guidance issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’ In particular we found the recording of required monitoring tasks was particularly thorough and effective. Equipment to manage medical emergencies was available in line with the guidelines issued by the Resuscitation Council (UK) and the General Dental Council. An effective system to ensure the availability and effectiveness of the equipment was developed. Audits of radiography and infection prevention and control were completed within recommended timescales and following guidance.

Partnerships and communities

Regulations met

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

Learning, improvement and innovation

Regulations met

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.