Balham Smile Clinic

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 had made the required improvements.

During our inspection of this key question, we found

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided:

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in the detailed 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.

Systems and processes were not embedded, and the inspection highlighted a number of issues and omissions.

The practice had a governance system that included policies and procedures. However, some policies were not reviewed on a regular basis, or monitored to ensure that they were embedded into the day-to-day management of the practice.

There were ineffective processes for managing identified risks. in relation to fire safety and Legionella.

There were ineffective systems for monitoring aspects of the management of the practice. These included systems to monitor staff training and ensuring that all equipment was tested in accordance with manufacturer’s instructions and other relevant guidance. Improvements were needed to the systems for ensuring that emergency medicines and equipment were checked, available and accessible.

Following our inspection we were told that the management arrangements had been strengthened and we were provided with details of improvements being implemented at the practice.

Staff feedback was obtained through meetings, surveys, and informal discussions. Staff did not always feel they were encouraged to offer suggestions for improvements to the service, or they said these were listened to.

The practice team was small and the dental nurse / manager had lead responsibilities for areas including safeguarding, Legionella, infection control and complaints. They told us they felt they needed more support to enable them to fulfil management roles as well as dental nursing duties.

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.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

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