Spirit of Excellence 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 not always effectively embedded within the practice. The inspection identified several issues and omissions, which were addressed promptly following our feedback.

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.

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

The provider had a complaints procedure, and they told us concerns and complaints were responded to appropriately; no complaints was received in the last 12 months.

Due to gaps in oversight and governance arrangements, staff’s day-to-day responsibilities were not always clearly defined, for example, the recording of hot and cold water temperatures. This indicated that improvements were required to ensure systems of accountability were in place to support effective governance. The provider acknowledged the importance of maintaining professional support and interaction within these roles, noting that they found aspects of the role isolating. To address this, they worked at another practice for two days each week and advised that similar flexibility would be made available to other team members where appropriate.

Staff feedback was obtained through 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. For example, clinical care record keeping improvements were implemented within the practice because of peer-to-peer feedback.

The practice had taken steps to improve environmental sustainability. For example, record-keeping and x-ray processes were digitised. We observed that cardboard boxes were retained, stored appropriately, and reused for posting items such as laboratory work, to reduce unnecessary waste.

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.