Clinical Governance Framework

Our policy focuses on the 12 themes directly associated with dental clinical governance. Cleveland Orthodontics will adhere to best practice and providing a high quality and safe service in line with the Clinical Governance Framework:

  1. Infection Control – Lead staff member: Nicholas J Huntley

    Cleveland Orthodontics will:

    • have implemented the minimum standard and is working towards the HTM01-05 best practice guidelines. The new service will achieve best practice.
    • have an up to date Infection control policy
    • have an up to date inoculation injury policy
    • have an up to date waste disposal policy
    • ensure that all staff undergo infection control training during induction
    • ensured that all our staff have an immunisation record
    • keep accurate records in relation to decontamination processes
    • record any incidents
    • audit our processes and procedures on a [time scale] basis
  2. Child protection – Lead staff member: Nicholas J Huntley

    Cleveland Orthodontics will:

    • seek identification, CRB and reference checks for all staff
    • have an up to date child protection policy
    • will provide staff with access to associated training
    • will hold and check employees employment records
    • audit this process on an annual basis.
  3. Dental radiography –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will ensure that all of our associated procedures and policies are in accordance with the IRR (1999) and IR (ME)R (2000). This will include:

    • Regular risk assessments of radiation facilities
    • a quality assurance system with audit
    • an ionising radiation policy
    • ensuring the protection of staff
    • X-ray malfunction plan, including how to manage an unintended over-exposure;
    • Records of staff training and updates.
    • X-ray equipment maintenance records
  4. Staff, patient, Public and environmental safety assessment –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will identify and minimise risks by regularly conducting risk assessments and checks in order to minimise risk. We will assess:

    • the types of treatment we provide
    • the range of patients we see and their individual needs
    • the policies and processes we use
    • building and environmental hazards such as waste, syringes, radiation, chemicals and medicines
    • risks to patients which are minimised through thorough recruitment processes, CRB checks, GDC registrations and renewals
    • dentists, DCPs and other staff’s CPD and training needs
    • risks to confidentiality in terms of paper based and computerised records
    • how information is recorded in the practice to ensure it is clear and accurate and therefore minimises risk
    • our access to services

    In addition to this we will:

    • meet all health and safety requirements
    • hold a health and safety policy
    • adhere to COSHH
    • hold a patient safety policy
    • have incident reporting procedures, monitoring and analysis
    • involve staff by informing them of safety issues
    • ensure all equipment complies with safety requirements
    • hold a inoculation injury policy
    • hold a infection control policy
    • hold a radiography policy
    • hold a waste disposal policy
    • hold an environmental policy

    We will adhere to:

    • Hazardous waste regulations 2005 and the management of waste amalgam/mercury
    • Health and Safety at Work Act 1974
    • Management of Health and Safety at work Regulations 1999
    • Workplace (Health, Safety and Welfare) Regulations 1992
    • Control of Substances Hazardous to Health Regulations 2002
  5. Evidence-based practice and research –  Lead staff member: Nicholas J Huntley

    Cleveland Orthodontics will ensure that:

    • relevant NICE Guidelines are followed
    • clinical care is informed by other evidence-based guidelines
    • existing care pathways and referral protocols are followed
    • where appropriate, principles of research governance are applied
    • Cleveland Orthodontics works to ensure that we employ evidence based practises to deliver high quality care to our patients

    In line with evidence-based practice we will also monitor clinical effectiveness and oral health gain. We will do this by:

    • keeping accurate patient records
    • monitoring data records and producing reports through our software [name]
    • providing reports to the PCT on request to contribute locally and nationally
  6. Prevention and public health –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will:

    • aim to provide services in line with local and national strategies
    • implement the DH prevention toolkit in day to day practice
    • provide smoking cessation
    • alcohol consumption advice
    • access for oral cancers and provide oral cancer awareness to patients
    • form links with local health care providers
    • have in place a patient safety policy
    • have in place an infection control policy
    • have in place a health and safety policy.
  7. Clinical records, patient privacy and confidentiality –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics has:

    • record keeping processes and procedures in place to allow for uniform practice
    • all staff receive training on record keeping, the Data Protection Act 1998, patient confidentiality
    • patient requests for their medical records are accepted and dealt with by Nicholas J Huntley, this is in line with the Data protection  Act
    • we follow Caldicott Guidelines 1997 and our Caldicott Guardian is Nicholas J Huntley
    • we have in place a confidentiality policy
    • we have in place a data protection policy
    • we have in place a data security policy
    • we use secure paper and electronic systems
  8. Staff involvement and staff development –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics ensures that:

    • all staff undergo a thorough induction process introducing them to documented policies and procedures
    • all staff receive a staff hand book and employment policies
    • all staff are aware of regulations such as NICE guidelines and HTM01-05
    • everyone understands what the practice is supposed to do
    • everyone understands their role in delivering the service
    • we hold regular team and individual meetings to share information
    • provide individuals with job specifications and employment/performance contracts
    • provide ongoing training, time for CPD and personal development plans
    • we involve staff in the audit process and provide feedback
    • ask staff to report areas of practice they feel can be improved
    • we conduct staff surveys on a [time] basis
    • we have an open door policy for staff to raise concerns at any time
    • we allow for concerns to remain confidential when requested
    • we have an equality and diversity policy
    • we have in place a policy where staff can raise concerns about the care provided by the practice
    • we provide staff with a minimum of basic life support training
  9. Clinical staff requirements and development –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will

    • ensure all new staff are working towards or GDC registered
    • ensure that GDC renewal deadlines are met
    • provide clinical supervision to staff
    • provided dedicated time to continuing professional development and help clinical staff to identify training needs
    • introduce clinical staff to all policies and procedures during induction training
    • provide all clinical staff with a performance agreement
    • hold an up to date underperformance policy
    • comply with GDC guidelines on patient consent
    • hold an up to date grievance policy and procedures
  10. Patient information and involvement handling, patient feedback –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics ensures that we

    • we will involve patients in the practice
    • are a patient centred practice
    • conduct annual patient surveys
    • have a patient suggestion box
    • hold annual patient focus groups
    • hold records to show where changes have occurred as a result of patient suggestions or complaints
    • have an up to date complaints policy and procedure
    • provide patients with information relating to NHS service and how to access out of hours care
    • monitor patients responses to our services and use these to continue our development
    • involve patients in their care and offer full explanations in all areas of their care
    • patient literature will be available and available in alternative languages when required
  11. Fair and accessible care –  Lead staff member: Patient information and involvement handling, patient feedback –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will

    • comply with the Race Relations (Amendment) Act 2000
    • ensure access is available through public transport links
    • ensure our building is DDA complaint and allows for equal access
    • our opening hours will be:
    Monday 08:00am – 5:45pm
    Tuesday 08:00am – 5:45pm
    Wednesday 08:00am – 6.00pm
    Thursday 08:00am – 5:45pm
    Friday 08:00am – 4:45pm
    Saturday 09:00am – 2.00pm
    • our dedicated emergency/urgent appointments will be:
    Monday 08:00 – 08:30am 10.30-11.00am 2.30-3.00pm
    Tuesday 08:30 – 09.00am 10.30-11.00am 2.30-3.00pm
    Wednesday 08:30 – 09.00am 10.30-11.00am 2.30-3.00pm
    Thursday 08:30 – 09.00am 10.30-11.00am 2.30-3.00pm
    Friday 08:30 – 09.00am 10.30-11.00am 2.30-3.00pm
    Saturday 12.00—2pm
    • emergency/urgent presentations outside of our slots will be triaged
    • provide access to interpreting services
    • produce literature in relevant languages
    • be patient centred and meet our patients access needs
  12. Clinical audit and peer review –  Lead staff member: Nicholas J Huntley
    Cleveland Orthodontics will:

    • conduct clinical audits to examine the different aspects of our practice, to make improvements where the need is identified and, from time to time, to re-examine areas that have been audited to make certain that a high quality of service is being maintained or further improved. These audits include patient satisfaction, clinical records and radiographs, infection control, IOTN and PAR.
    • have peer reviews to provide our dentists the opportunity to review aspects of our practice. The aim is to share experiences and identify areas in which changes can be made to improve the quality of service offered to patients. These include IOTN, PAR, treatment planning.
    • have in place clearly defined processes that allow for audits and peer reviews to take place in a structure manner to ensure that we get easily translated results for our auditing reports. These reports are then used as part of our continuous improvement processes.
    • ensure we  have policies in place for all of our procedures. Our policy lead will provide policies for any new processes that are introduced to Cleveland Orthodontics.
    • We will audit our policies, processes and procedures in line with the clinical governance framework