Thamesview Dental Surgery

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. However, improvements were required to ensure that policies were reviewed regularly and that obsolete policies were discarded or archived.

Systems and processes were embedded for most part. Where the inspection highlighted issues and omissions staff were responsive in ensuring that 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.

There were some processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems for learning and quality assurance. However, the provider should ensure that audits are completed in line with recognised guidance. We noted that radiograph audits included fewer than 100 images and did not include all clinicians. The provider should also ensure that six-monthly audits are implemented.

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 good governance.

Staff feedback was obtained through meetings 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. For example, staff told us they raised concerns regarding workflow and appointment scheduling. As a result, adjustments were made to improve time management and reduce delays.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, we saw that the provider discussed the outcomes of the Friends and Family Test with staff and how the service could be improved.

The practice had taken steps to improve environmental sustainability. For example, workflow processes, including radiographs, clinical record keeping and referrals, had been digitised, reducing the need for paper.

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.