Stokenchurch Dental

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 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 and were reviewed on a regular basis.

Systems and processes were not fully embedded. 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 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 not always effective processes for identifying and managing risks. However, the practice had systems in place for investigating incidents and accidents, and for receiving, reviewing 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.

We noted innovative approaches to providing person-centred care. For example, patients were actively involved in decisions about their treatment through the use of clinical photographs and written treatment plans. The practice also provided follow-up telephone calls for patients who had received complex treatment to check on their recovery and wellbeing.

Staff had clear responsibilities, and systems of accountability.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to suggest improvements to the service and reported that their views were listened to and acted upon where appropriate. For example, appointment reminder emails were amended to provide patients with more advance notice, and reception staff were supported to provide clearer information about appointment fees following patient feedback.

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, it had reduced its use of single-use plastics by replacing disposable mouthwash cups with reusable stainless-steel cups that could be sterilised and reused. The practice also promoted recycling and made use of digital systems to reduce paper consumption.

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.