Maryport Smile Centre

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.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 was not providing well-led care and treatment.

Findings from our inspection demonstrated that oversight and governance was not effective. Systems and processes were not embedded, and the inspection highlighted a number of issues and omissions in relation to the systems to ensure the safety and suitability of the premises.

Where audit had been undertaken, this was not used effectively to drive improvement and learning.

Our inspection highlighted a number of concerns. There were ineffective processes for identifying risk and managing risks identified from safety reports and assessments. We have documented these concerns and omissions in an action plan request to the provider.

When providing feedback, the practice team were responsive, telling us they would act on areas requiring improvement 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.

Concerns and complaints were responded to appropriately. Staff told us that outcomes were discussed to share learning and for improvement.

Where we could see staff had clear responsibilities, systems of accountability to support good governance were not in place.

Staff feedback was obtained through meetings and informal discussions. The practice gathered feedback from patients and responded accordingly. For example, responding to on-line feedback.

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.