University Dental Practice

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.

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 embedded, and the inspection did not highlight any issues or omissions.

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).

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

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, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. For example, parking for staff was very limited so the provider engaged with a neighbour to rent extra car parking spaces. Additionally, staff requested more tablet devices to securely update patient information. This was implemented by the practice manager.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, the provider appointed a managed impartial feedback system which sends feedback requests to every patient. Over 24000 requests have been made to date, and all feedback is collated and reviewed regularly. Following feedback that there appeared to be overbooking of appointments and lengthy waiting times, the provider redesigned the appointment schedules, allowing structured breaks for instrument turnover and contemporaneous record keeping. This immediately improved waiting times and workflow. Additionally, online booking was implemented and new waiting room chairs were purchased as a result of patient feedback.

The practice had taken steps to improve environmental sustainability. For example, the digital workflow reduced waste and transportation use. Recycling was implemented where possible. Sensor controlled lighting was present in some areas of the practice, reducing unnecessary energy use.

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.