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

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.

The practice had recently undergone a change in management in the weeks leading to the inspection. The new management was aware of some gaps in oversight and had proactively addressed some of these prior to our inspection visit.

Most systems and processes were embedded, and processes for identifying and managing risks were mostly effective. Our inspection did highlight some minor shortfalls in oversight of systems and processes related to medical emergency kit checks, COSHH risk assessments, compressor servicing, fire safety checks, recruitment procedures and completion of staff training.

We found staff were open to discussion and feedback, and staff worked together in such a way that where the assessment identified minor areas of risk which required improvement, these were acted on immediately.

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

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

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

Staff feedback was obtained through meetings 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. For example, allocating more time for trainee nurses to complete their coursework.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, making practice renovations following patient feedback.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible, used digital systems to reduce paper waste, turned off electrical devices and lights when not in use and used reusable instruments where possible to reduce single use plastics.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We noted the radiography audit sample size should be increased and conducted every 6-months in line with national guidance.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records. We noted some confidential staff files were stored in an accessible location. We discussed this with staff and the practice submitted evidence following the inspection that this had been rectified.

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.