Principal Dentistry

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 and provider 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 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. The practice did not have formal systems in place to collect feedback from patients, the public and external partners. We were told that patients were vocal and expressed their satisfaction with the practice or raised comments verbally to staff as and when needed. Online reviews seen were all positive but had not been responded to by the practice.

Systems and processes were embedded, and staff worked together in such a way that the assessment did not highlight any significant issues or omissions. Where the assessment identified areas which required improvement these were acted on immediately. The information and evidence presented during the assessment was clear and well documented. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV) 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 had systems in place to respond to concerns and complaints appropriately. Outcomes would be discussed to share learning and improve the service. The practice had not received any formal complaints within the last 3 years. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We noted that the provider had not completed an audit of antimicrobial prescribing. The latest infection prevention and control audit was not scored and there was no action plan documented. The radiography audit was completed at the required frequency but did not include the correct sample size. We were assured that scoring and action plans would be completed as required for the infection prevention and control audit and the sample size increased for the radiography audit going forward.

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.