Improve Your Smile Limited

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. However, the provider should ensure that policies reflect current working arrangements at the practice.

Systems and processes were generally embedded. Where issues or omissions were identified during the inspection, staff took prompt action to address them or had appropriate action plans in place. For example, arrangements had been made to complete an external fire risk assessment, references had been obtained for some members of staff, and we saw that the provider had contacted the compliance company to query records for staff training.

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.

At the time of the inspection, the provider was in the process of decommissioning the use of closed-circuit television (CCTV).

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

The practice had systems and processes in place to support learning, quality assurance and continuous improvement. However, these processes were not always used effectively to identify and address areas for improvement. For example, the antibiotic audit did not identify that prescribing was not always in line with recognised guidance where no justification had been documented. Furthermore, although the radiography audit identified that 12% of images were not acceptable, this outcome had not been queried to determine whether any remedial action was required.

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 had access to a range of specialist services onsite.

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.

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, digital workflow processes were used for radiograph and patient care records. Staff told us they were encouraged to recycle and switch off equipment when not in use and at the end of the working day.

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.