Nantwich Smile Design

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 they have been put right by the provider.

During our assessment of this key question, we found

systems and 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 were not effective.

systems and processes to assess, monitor and improve the quality and safety of the services being provided were not effective.

This resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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.

We found staff to be open to discussion and feedback.

The practice staff demonstrated a transparent and open culture. They were responsive to discussion and feedback to highlight risks and took appropriate action to address these.

Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management.

Feedback from staff was obtained through informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

Staff stated they felt respected, supported and valued. They were proud to work in the practice.

Staff told us how they collected and responded to feedback from patients, the public and external partners.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible and turned off equipment and lights when not in use.

We noted improvements were required to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire, Legionella, lone working, sharps safety, and health and safety.

Improvements were required to some of the practice’s systems and processes to improve management oversight. The on-site assessment highlighted some issues and omissions.

The practice had not conducted risk assessments to minimise the risk that could be caused from substances that are hazardous to health.

The practice had ineffective systems to review and investigate incidents and accidents. Improvements were required to ensure all follow up actions were recorded, and the documentation of these was stored securely.

The practice had ineffective systems for receiving and acting on patient safety alerts, recalls and rapid response reports.

The practice’s governance systems required improvements to ensure policies and procedures were reflective of the practice protocols and consistently adhered too. However, we did note the policies were in line with national guidance.

The practice had ineffective systems to assess, monitor and manage risks to patient and staff safety. After the assessment, evidence was sent that confirmed the provider was in the process of introducing systems to address these. These systems were yet to be embedded.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. In particular, the infection control and prevention audits were not routinely carried out every 6 months. Antimicrobial prescribing audits, clinical record keeping audits, conscious sedation audits and implant failure audits were not carried out. Improvements were required to ensure all audits conducted have an action plan, which is regularly reviewed to drive improvement.

Staff password protected patients’ electronic care records and complied with General Data Protection Regulations (GDPR). However, we observed on the day of assessment that computers were left unattended whilst logged in. We discussed this with staff and were assured this would be addressed.

However, the practice responded to concerns and complaints appropriately.

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.