Acton Vale Dentists

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 significant issues or omissions. Areas requiring improvement were acted on immediately.

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. The practice had a treatment coordination room where private conversations could be held with patients.

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.However, audits were not always fully reflective of practice processes. We discussed this with staff and were assured that this would be reviewed and addressed for future audits.

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

We noted innovative approaches to providing person centred care. For example, the practice had identified which treatment rooms were the quietest and actively booked patients with sensory impairments or additional needs into these rooms. Where possible, patients were offered the same time appointments when booking in.

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. There was a suggestion box in the staff room, and these were discussed at practice meetings. The practice manager had training and experience in wellbeing and implemented “wind down Wednesdays” where staff could spend time together at the end of the day. Each receptionist was buddied up with a dentist to ensure good communication and support.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. Friends and Family test forms were sent out once a week, results collated and shared with staff.

The practice had taken steps to improve environmental sustainability. For example, turning off lights and equipment when not in use, ordering materials responsibly and adopting a digital workflow 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.