Keep Smiling UK

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

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided.

a lack of systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

This resulted in a breach of Regulation 17, Good governance.

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 had a governance system that included policies and procedures, which were accessible to staff. However, these were not always followed by the provider.

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 effective processes, 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, including undertaking audits. However, the auditing process required improvements, Specifically, antimicrobial prescribing audits had not been conducted, the disability access audit action plan did not address how the practice would address some disabilities including hear and sight difficulties. While radiographic (February 2025 ) and infection control ( January 2024) audits were carried out ,there was no evidence of subsequent or previous audits, with the provider stating prior audits had been archived. This raised concerns that these audits were not consistently being completed six-monthly in line with guidance. Following the inspection the provider confirmed these audits would be conducted six-monthly going forward.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

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, recycling arrangements were in place.

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.