St Mary's 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 embedded, and the inspection did not highlight any issues or omissions.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely. However, improvements were needed to ensure records containing personal information were managed in line with data protection requirements. For example, completed pages in the accident book had not been removed and stored securely, which meant personal information could be viewed by others.

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.

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 clinician used digital technologies, including intraoral scanning and clinical photography, to help patients better understand their oral health, treatment needs and expected outcomes. Images and scans were stored within patient records and used during discussions to provide personalised explanations and support informed decision-making. The clinician also worked closely with dental laboratories to improve communication and treatment outcomes. They demonstrated a commitment to continuous learning, regularly attending courses, webinars and international training events to identify innovations and best practice that could enhance patient care.

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, following staff feedback, the practice introduced small boxes for transporting X-rays for processing to support infection prevention and control measures. A whiteboard had also been introduced in the decontamination room to improve communication between staff, enabling issues to be recorded, monitored and actioned effectively.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, patients had requested additional appointment reminders by email. The practice had also acted on feedback regarding accessibility by developing a ground-floor surgery to improve access for patients with limited mobility.

The practice had taken steps to improve environmental sustainability. For example, it had introduced instrument treatment packs to reduce the need for individually pouched instruments, increased the use of digital systems to minimise paper consumption, and encouraged staff to switch off lights and equipment when not in use. The practice also promoted recycling and reused packaging materials, such as postal boxes, where appropriate to reduce 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.