Illume Smiles - Queens Road

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.

The practice had governance systems in place; however, aspects of monitoring, documentation and oversight required strengthening to ensure that all risks were consistently identified, assessed and mitigated.

At the time of the inspection, there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered. However, we have been assured by the provider that they have taken steps to appoint a registered manager.

Staff had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office.

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 and were reviewed on a regular basis.

Systems and processes were in place; however, aspects of monitoring, documentation and oversight required strengthening to ensure that all risks were consistently identified, assessed and mitigated.We found shortfalls in appropriately assessing and mitigating risks in relation to the control of substances hazardous to health, recruitment, infection prevention and control, data protection (closed circuit television) and fire safety management.

The provider should take action to ensure the regulated activities at Illume Smiles – Queens Road are managed by an individual who is registered as a manager.

There were effective processes for investigating incidents and accidents, and for receiving and acting on safety alerts.

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.

The practice had not implemented protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner’s Office.

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.

Staff had clear responsibilities, and systems of accountability.

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 and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, the practice was paperless where possible, all clinical records were completed digitally. Patients were asked if they would like their appointments emailed over to them rather than have a card printed.

Staff segregated waste both clinically and non-clinically and recycled where possible.

All equipment and lights etc were turned off when not in use and at the end of each day.

Staff told us how they went over and above to support their patients. They walked patients to their cars with umbrellas when it was raining. They sent birthday or anniversary cards to patients celebrating big milestones.

Clinicians worked on their day off to fit patients in before important events such as weddings.

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.