3 Step Smiles 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 the provider has made the required improvements.

During our inspection of this key question, we found

systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk were not effective.

systems and processes to assess, monitor and improve the quality and safety of the services being provided were not effective.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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 practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. Improvements were required to ensure these were reflective of the practice protocols.

The practice’s processes for identifying and managing risks, were not always effective. Improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire safety, sharps safety, lone working and the oversight of medical emergency arrangements.

Improvements were required to ensure the practice responded to concerns and complaints appropriately and consistently followed their complaints procedure.

Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations (GDPR). On the day of inspection, we highlighted online review responses were not in line with GDPR. The practice acted immediately to resolve this and assured us this would be addressed going forward.

Improvements were required to ensure systems to review, investigate and document incidents and accidents are consistently followed. In particular, reflecting on and documenting shared learning.

The practice had installed closed-circuit television (CCTV) to improve security for patients and staff. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).However, we noted a Data Protection Impact Assessment (DPIA) had not been carried out to assess the purpose, necessity, and risks prior to installation of CCTV. Following the inspection, the practice sent evidence that a DPIA had been completed.

The practice had taken steps to improve environmental sustainability. For example, the practice promoted energy saving where possible and turned off electrical devices and lights when not in use.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

There were processes for receiving and acting on safety alerts.

Staff feedback was obtained through meetings, and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

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.