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 Clinical governance policy

This clinical governance policy describes the way our practice strives to continuously improve the quality of our service and delivers a consistent standard of care for our patients.


Our clinical governance policy follows the Department of Health’s framework, adapted for primary dental care and focuses on aspects concerning (i) the practice team, (ii) our patients, (iii) practice safety, and (iv) clinical issues.


Clinical governance is about managing quality and developing practice management systems to help us track our progress by –


  • knowing what is supposed to be done, how it should be done and why

  • knowing who it is supposed to be done by

  • being able to show that it has been done in the right way every time, and

  • learning from mistakes to prevent them happening again.


The lead for clinical governance issues at the practice is undertaken by Vicky Hatton.


This policy is reviewed annually and more regularly if changes occur within the practice.


1.The practice team


Staff involvement and staff development
  • The practice has systems in place for the safe recruitment of employed and self-employed workers.

  • Every member of the team has an up-to-date job description and contract of employment

  • The practice has the full range of employment policies

  • All new members of the dental team undertake induction training in the practice procedures and protocols

  • Annual appraisals are held and all staff have personal development plans

  • Individual, team and practice training needs are identified and, where appropriate, training is provided

  • Records of training are maintained for each team member

  • There are regular staff meetings to share information and make plans for the practice and the team

  • The team is open in dealing with issues of performance

  • There is a reporting line for staff who have concerns about any aspect of the practice or another member of the team

  • There is a practice policy for handling complaints.


Clinical staff requirements and development
  • All qualified clinical staff are registered with the GDC.  Trainee dental nurses are working towards a qualification that will allow registration with the GDC

  • Registration/practising certificates are checked annually

  • GDC requirements for CPD are complied with

  • The practice has a training policy

  • The practice has a policy for dealing with underperformance.





Patient information and involvement
  • Patient treatment plans and care are always developed in consultation with the patient; the patient’s choice is followed, wherever possible. Where it is not possible to comply with the patient’s choice and explanation is provided

  • The costs involved with various treatment options are made known to patients and where there are changes to the costs, the patient is informed and their consent to proceed is sought

  • Patients feel involved in decisions about their care

  • All patient records show clearly how consent was obtained, whether written or oral

  • Patients having extensive treatments, receive written treatment plans

  • Patients are actively involved in developing the practice’s services

  • There is an annual cycle of patient surveys

  • The team has looked at the possibility of  holding focus groups and, where appropriate, organised them

  • All complaints are acted upon and used as learning tools for the team

  • All staff at the practice have undergone criminal records checks

  • The practice has a safeguarding patients policy and members of the team know what to do if child abuse is suspected.


Clinical records and confidentiality
  • The practice undertakes regular random audits of patient records

  • All new clinical staff have an induction session on practice  record-keeping standards

  • Data protection notification is up-to-date

  • All staff understand and apply the data protection principles

  • The practice computer or manual records systems are secure

  • All staff understand and apply the principles of confidentiality

  • Requests for access to medical records by patients are dealt with promptly

  • The practice has a publication scheme under the Freedom of Information Act.


Fair and accessible care
  • The practice makes every effort to welcome patients in wheelchairs, with hearing or vision impairments, with learning difficulties, patients who are frail and/or elderly patients and who have other special needs

  • The practice has an equal opportunities policy that includes provisions for patients and other customers requiring routine and urgent care to be seen.



3.Practice safety  


Infection control
  • The practice has an infection control policy that complies with current guidelines. All team members have a copy

  • Everyone receives training in infection control with regular updates to ensure that the practice procedures are understood by everyone and implemented rigorously

  • Records of training are maintained

  • Appropriate personal protection is provided

  • There is a practice protocol for dealing with inoculation injuries

  • Fergus Brown is responsible for implementing infection control procedures throughout the practice.

Dental radiography
  • Everyone involved with dental radiography is appropriately trained and has attended update courses as required. Records of staff training and updates are maintained

  • The radiation protection file is maintained

  • The practice protocol for referring patients is followed routinely

  • All radiographs are justified

  • Guidelines exposure settings for all types of radiographs are in place

  • Equipment is maintained and tested according to manufacturer’s recommendations

  • A quality assurance programme is in place.


Staff, patient, public and environmental safety assessment
  • There is a written safety policy, which has been brought to the attention of everyone that works in the practice

  • Systems are in place for reporting accidents and injuries

  • Employees using display screen equipment are assessed

  • A fire risk assessment has been carried out

  • A first-aider or appointed person is present when the practice is open

  • Stress-related complaints are treated seriously and investigated fully

  • Autoclaves and air-receivers are inspected according to written schemes of examination

  • A practice risk assessment has been carried out and everyone is aware of its findings

  • Waste is segregated and stored safely prior to disposal

  • Everyone receives training in dealing with a medical emergency

  • The practice has a patient safety policy and systems are in place for reporting and investigating patient safety incidents

  • Systems are in place for the storage, recording and dispensing of medicines

  • The practice has a protocol for selecting new equipment and reporting incidents involving medical devices



4.Clinical issues


Evidence-based practice and research
  • The practice has access to Evidence-based dentistry

  • NICE guidelines are adopted, where appropriate

  • SIGN publications are referred to, where appropriate

  • The team can demonstrate that it delivers care according to selected clinical guidelines.


Clinical audit and peer review
  • There is an annual cycle of clinical audit involving the team

  • The team can demonstrate changes they have made as a result of the audits

  • Referrals to DCPs are made in writing on a standardised form

  • Laboratories used by the practice are registered with the Medicines and Healthcare products Regulatory Agency

  • Procedures are in place for dealing with serious and untoward incidents

  • There is a system for dealing with poor performance.

Prevention and public health
  • We aim to provide services in line with local and national strategies

  • Oral cancer screening is carried out routinely

  • Advice on tobacco use cessation is available

  • The practice participates in National Smile Week.

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