SpaDental Tewkesbury

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.

A registered manager is legally responsible for the management of services for which the practice is registered. At the time of the inspection there was no registered manager in post, which is a condition of CQC registration.

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.

Systems and processes were generally embedded, and the minor governance issues and omissions referred to in this report were acted on immediately by the provider.

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.

There were processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts. Where we did find any gaps in this oversight, the provider gave assurance that these would be addressed immediately, for example, in relation to fire risk assessment, staff recruitment records and CPD that required completion by clinicians.

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

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff had clear responsibilities, and systems of accountability to support good governance.

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 generally listened to and acted upon, where appropriate. The leadership team told us they were always looking for better ways to communicate with staff across the practice.

Feedback from patients, the public and external partners was collected to which the practice responded.

The practice had taken steps to improve environmental sustainability. For example, there were separate waste bins for general and recyclable waste and the practice is cutting down on using single use items, where possible.

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.