Victoria House 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 were reviewed on a regular basis.

Systems and processes were mostly embedded and most processes for identifying and managing risks were working effectively. However, we identified some areas for improvement. During the inspection, staff were open to discussion and feedback. After the inspection, evidence was sent to demonstrate areas requiring improvement were acted on immediately.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records were stored securely and complied with General Data Protection Regulations.

There were effective processes for 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 practice had a dedicated waiting area for children which included a small table and chair, colouring equipment and children’s books with toys available for small children.

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, staff suggested a centralised system for instrument management. This had been implemented and staff spoke positively about the new system.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, patients suggested a full-length mirror in the accessible toilet that could be used by wheelchair users instead of an over sink mirror. The practice has now installed a full-length mirror for patient use.

The practice had taken steps to improve environmental sustainability. For example, the practice has waste recycling bins in the staff room to encourage recycling.

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.