• Dentist
  • Dentist

New Square Dental Surgery

35 New Square, Cambridge, Cambridgeshire, CB1 1EZ (01223) 506492

Provided and run by:
Dr Monica Bhardwaj

Report from 25 July 2024 assessment

On this page

Well-led

Regulations met

Updated 17 December 2024

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.

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

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 and responded to feedback from patients.

Systems and processes were embedded, and staff worked together in such a way that the assessment did not highlight any significant issues or omissions. The information and evidence presented during the assessment was not always clear or well documented and multiple documents could not be located on the day of the inspection. We found that there was not an effective system in place to ensure all policies, protocols and procedures were accessible to all members of staff. Improvements could be made to ensure these were always readily accessible. The practice had information governance arrangements and 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 (GDPR). We saw there were clear and effective processes for identifying and managing risks, issues and performance. The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice told us they responded to concerns and complaints appropriately, however improvements could be made to ensure information regarding the complaints process was on display for patients. Following the inspection, we saw that this information was now being displayed in the waiting area. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised 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.