U Smile Dental Practice

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.

During our inspection 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 might be at risk.

The registered person had systems or processes in place that were operating ineffectively in that they failed to enable the registered person to assess, monitor and improve the quality and safety of the services being provided.

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.

We found staff to be open to discussion and feedback. The provider was receptive to feedback on areas where improvement was needed and provided evidence to show where immediate action had been taken to address some of the concerns identified.

The practice staff demonstrated a transparent and open culture in relation to people’s safety. However, improved oversight was needed to ensure there was an understanding of the essential requirements and regulations.

We found the provider had the values and commitment to deliver high quality sustainable services. However, the lack of oversight of training, ineffective risk management and not always adhering to published guidance in respect of infection prevention and control all impacted the day-to-day management of the service.

The information and evidence presented during the assessment was not always clear, available and well documented.

Policies and procedures were not regularly reviewed, and we were not assured that policies included relevant and up-to-date information staff could confidently refer to. For example, the external contact details for staff to share a concern in the whistleblowing policy was out of date.

There were ineffective processes for identifying and managing risks, issues and performance. We identified concerns around the management of risks associated with management of medical emergencies, management of used sharps, infection prevention and control, COSHH, radiation protection, lone working, recruitment and training monitoring.

The practice had systems for receiving and acting on safety alerts. However, processes to review and investigate incidents and accidents were limited. Immediately following the inspection, the provider implemented a log to record significant events as an opportunity for learning.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Audits for radiography, record keeping, antimicrobial prescribing and disability access were not used to identify areas for improvement. There were no systems in place for monitoring training to ensure that all staff received training appropriate to their role at required frequencies.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff feedback was obtained through informal discussions. Staff said they were encouraged to offer suggestions for improvements to the service.

The practice gathered feedback from patients, the public and external partners though surveys and digital reviews.

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.