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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breaches we found at our assessment on 29 October 2024.

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.

At the assessment on 29 October 2024, we had highlighted where improvements should be made. At the assessment on 5 March 2025, we found the practice had made the following improvements:

Improvements were made to the practice’s systems and processes to improve management oversight. The on-site assessment did not highlight any significant issues and omissions.

The practice had made improvements to ensure that the practice’s systems and processes were followed, and risks managed appropriately. In particular, the risks associated with fire, Legionella, health and safety and staff recruitment.

The practice had systems to assess, monitor and manage risks to patient and staff safety. In particular, the practice had conducted a health and safety risk assessment and a sharps safety risk assessment. Although we noted improvements were required to ensure the sharps risk assessment reflected practice protocols, we discussed this with staff and were assured these would be actioned.

The practice had conducted risk assessments to minimise the risk that could be caused from substances that are hazardous to health.

The practice had systems to review and investigate incidents and accidents. However, as no incidents or accidents had occurred since the last assessment, we could not check if these were embedded, but staff showed understanding of the system.

The practice had introduced systems for receiving and acting on patient safety alerts, recalls and rapid response reports. Improvements should be made to ensure these were regularly checked.

The practice had implemented systems and processes for learning, quality assurance and continuous improvement. In particular, the practice had implemented infection control and prevention audits, disability access audits, and clinical record keeping audits. The practice had implemented a log for future implant failure audits but had not had any failures at the time of the follow-up assessment. Antimicrobial prescribing audits were not carried out. Improvements were required to ensure all audits conducted have an action plan, which is regularly reviewed to drive improvement. In particular, the disability access audit.

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

The practice should improve their arrangements for ensuring good governance and leadership are sustained in the longer term.

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.