Archived: Smmmile

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

The registered person had ineffective systems or processes to enable them 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.

Improvements were required to some of the practices systems and processes to improve risk management, governance and oversight. In particular, oversight of fire safety, radiography, Control of Substances Hazardous to Health (COSHH), Legionella and servicing of equipment.

The inspection highlighted some issues and omissions. The practice submitted evidence following the inspection to show areas requiring improvement were being addressed. We will follow-up these improvements to ensure they are embedded.

The provider was open to discussion and feedback to improve the practice. They were open and honest about systems, policies and documents that were either missing or misplaced when we requested to see them. Whilst focusing on supporting the delivery of patient care, their capacity to maintain effective oversight of systems had been affected.

Improvements were required to the governance systems to ensure policies and procedures were regularly reviewed and easily accessible to staff.

The practice had some systems and processes for learning, quality assurance and continuous improvement. They had carried out radiography and infection prevention and control audits. However, these had not been carried out every 6-months as required by nationally recognised guidance and they did not identify areas of improvement.

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 mostly 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.

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 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.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled 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.