Smiles By Gurms

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.

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

During our inspection of this key question, we found ineffective systems or processes to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

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.

The practice had a governance system that included policies and procedures, which were accessible to staff. However, we found they were not always reviewed on a regular basis.

The practice’s management systems for monitoring and mitigating various risks required improvement. In particular, risks associated with medical emergencies, equipment, dental radiography, fire safety and Legionella.

Systems and processes for learning, quality assurance and continuous improvement required strengthening, including undertaking audits according to recognised guidance.

The practice did not always manage concerns and complaints effectively, and a culture of continuous improvement was not consistently demonstrated.

Many of the areas requiring improvement were acted on immediately demonstrating the practices commitment to improving the service for both staff and patients. We will be following up on our concerns to ensure the provider has made the required improvements.

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.

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

There were processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service; however, they said these were not always listened to or acted upon.

The practice had taken steps to improve environmental sustainability. This included recycling and turning lights off when not in 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.