Elm Park 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, and most were reviewed on a regular basis. The service had recently undergone extensive renovation and refurbishment. To minimise disruption to the continuity of patients’ care and treatment, the practice remained operational throughout the works. At the time of our inspection, most of the refurbishment had been completed with only minor snagging work remaining. The management team explained that this had caused disruption to some of their systems and processes. The inspection highlighted some issues and omissions; however, the team was responsive and areas requiring improvement were addressed 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. Tablet devices were used to enable patients to complete or update medical history and to review and electronically sign treatment plan and other documents.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

There were processes for identifying and managing risks, however, improvements were required to ensure identified risks were appropriately mitigated in a timely manner, for example, servicing of the fire alarms, staff training and the management of legionella.

Processes were in place for investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had systems and processes for learning and quality assurance and demonstrated 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.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys, 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, the provider introduced specialist treatment.

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, clinical and administrative workflows were digitised, including x-rays, record keeping, the use of electronic treatment claim forms- these all reduced the use of paper. We observed that appropriate arrangements were in place to ensure that waste was segregated and disposed of correctly. Staff commented “we recycle our ink cartridges and boxes to the recycling centres; we have a company that comes to collect the amalgam waste so it would be disposed in a correct way…”

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.