Elstree Dental

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.

At the time of the inspection there was no registered manager in post as required as a condition of registration. A registered manager is legally responsible for the management of services for which the practice is registered. The practice advised they will be addressing this.

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 embedded, and the inspection did not highlight any significant issues or omissions. The provider was responsive to our feedback and 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, and records were stored securely and complied with General Data Protection Regulations.

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits in infection prevention and control, record keeping radiography and antimicrobial prescribing according to recognised guidance.These audits could be improved by including documented learning points to continuously drive improvement.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. Information for patients advising them how to complain was displayed in the practice waiting area.

Staff had clear responsibilities, and systems of accountability to support good governance.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

Staff feedback was obtained through meetings, digital chats 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.

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

The practice had taken steps to improve environmental sustainability. For example, through the use of recycling and digitalised patient records.

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.