Smile Together Lescudjack (Penzance)

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 the registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

We also found concerns that the registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person to maintain securely such records as are necessary to be kept in relation to persons employed in the carrying on of the regulated activity or activities.

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 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 assessment highlighted areas where improvements were needed.

The provider did not have effective systems in place to ensure proper oversight of the end to end decontamination process to ensure this was in line with current guidance.

The provider did not have effective systems in place to ensure all staff were appropriately qualified and trained for the roles they undertake within the practice.

The provider did not have effective systems in place to mitigate the risk of Legionella or other bacteria developing in water systems, as per the risk assessment and current guidelines.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. The practice was migrating to the new electronic governance system having acknowledged the need to modernise the way information was stored and retrieved.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.Improvements were needed to ensure radiography audits were conducted every 6 months using a reasonable sample in line with legal requirements.

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

When giving feedback following our assessment, staff and managers were open and responsive to our findings and took some immediate actions to mitigate risk.

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.

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 to support good governance.

The practice had taken steps to improve environmental sustainability, which included reducing in-house printing, purchasing environmentally friendly cleaning products, and reducing the use of plastic within the practice.

Feedback from patients, the public and external partners was collected to which the practice responded.

Staff feedback was obtained through meetings, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service. The practice has a representative on the Shareholder Impact Board to relay information from the staff.

We received mixed feedback highlighting that communication and feedback could be improved.

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.