The Orthodontic Centre (Wokingham)

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. The provider had made improvements in relation to the regulatory breach we found at our previous inspection on 5 October 2023.

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.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises. At the assessment on 31 July 2024 we found the practice had made the following improvements to comply with the regulation: Staff told us that there have been significant improvements to the governance, management and oversight within the practice, with an impetus on clearly defined roles, responsibilities and reviews of the systems and processes that they support. For example, fire safety is managed effectively in the practice, with trained fire wardens taking responsibility for checks of fire safety equipment and managing fire drills; Recruitment and training logs have been improved and are updated regularly by the practice management team, ensuring that new staff have the appropriate documentation prior to commencing work and are supported in completing their on going training and clinical professional development. Since our previous inspection, the practice has held regular staff meetings, which were well documented and the minutes of these were shared with staff who were unable to attend.

At the assessment on 31 July 2024 we found the practice had made the following improvements to comply with the regulation: We saw a new fire risk assessment had been completed by an external professional company and recommendations made within this had been actioned by the practice. Accompanying logs and checks of the fire alarm and equipment, including checks of the fire alarm, emergency lighting and fire extinguishers were completed accurately and dated appropriately. We also saw current servicing records for these, and a schedule was in place to ensure these were completed at the appropriate timescales. We found the practice had made improvements to their recruitment process, including an updated policy and trackers for both recruitment and training. We saw that new staff had the correct Data and Baring Service (DBS) checks in place, references obtained and where applicable for clinical staff, they could show evidence of their Hepatitis B immunity level. We also saw that training had been completed in all recommended topics for all staff. The practice had implemented an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council. In particular, ensuring the correct dating of the checks were recorded, the correct preparation of all medicines were available and out of date items were removed. Data security of the accident book had also been considered and improved. Since our previous inspection, the Data Protection Impact Assessment (DPIA) for the provision of Closed-Circuit Television (CCTV) has been reviewed and updated to include information as required by the Information Commission Office (ICO). A system for collecting patient feedback and analysing the information to make improvements to the service had been introduced. Infection Prevention and Control audits were being carried out 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.