Vaughan 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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

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.

We found staff to be open to discussion and feedback. The practice staff demonstrated a transparent and open culture in relation to people’s safety. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through meetings and informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they collected feedback from patients, the public and external partners through online reviews, surveys and a suggestion box and to which the practice responded. The practice had taken steps to improve environmental sustainability. For example, they segregated general waste, and patient care records, with the exception of X-ray images, were digital.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. Systems and processes were mostly embedded, and the assessment did not highlight any significant issues or omissions. Areas requiring improvement were acted on immediately. 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. We saw there were clear and mostly effective processes for identifying and managing risks, issues and performance. Improvements to the processes for managing risks associated with substances hazardous to health, lone working and Legionella water temperature management were implemented immediately following our feedback. The practice had systems to review and investigate incidents and accidents and implemented a system for receiving and acting on safety alerts on the day of the assessment. The practice responded to concerns and complaints appropriately. Information about how to complain was displayed in the practice waiting area. Staff discussed outcomes to share learning and improve the service. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. Improvements could be made by undertaking radiography audits 6-monthly in-line with 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.