Smileright Dencare Limited - Basingstoke

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• 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 has made the required improvements. During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the ineffectiveness of the systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. 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 evidence category 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. However, improvements were needed to ensure that leaders had sufficient oversight of the practice on a day-to-day basis.

Additionally, the information and evidence presented during the assessment was not always clear and well documented. Improvements were required to ensure information about systems and processes was readily available for staff and embedded in the day to day running of the practice. Although a compliance system was in use by the organisation, the management had limited access to this. Whilst we were told the policies and procedures were accessible to staff, we did not see evidence that staff had read and understood these. In addition, we were not assured that there was an effective system in place for reviewing and updating policies, procedures and protocols on a regular basis. There was scope to ensure policies were reviewed annually, were accessible to all staff and were seen and signed once read by all staff.

Feedback from staff was obtained through remote meetings and informal discussions. Staff feedback demonstrated that the remote nature of these conversations required review.

Improvements could be made to ensure processes to support and develop staff with additional roles and responsibilities were in place and embedded within the practice team. Not all staff had received appraisals to support development.

Staff told us that feedback from patients was not requested by the service, and that they received reviews online, but did not review or respond to these. The practice should implement processes and systems for seeking and learning from patient feedback with a view to monitoring and improving the quality of the service.

The practice had taken steps to improve environmental sustainability. For example, paper usage was reduced with the use of digital systems and energy efficient lighting was installed.

We saw that improvements were required to the processes in place to identify and manage risks in relation to fire safety, hazardous substances, infection prevention and control, and staff recruitment and training.

The practice had information governance arrangements and staff were aware of the importance of protecting patients’ personal information.

Staff password protected patients’ electronic care records and complied with General Data Protection Regulations (GDPR).

Processes for identifying and mitigating risks, issues and performance were not always clear or effective. Actions recommended in the fire risk assessment had not been completed, issues identified in the control measures for Legionella were not escalated and acted on. There was no risk assessment for sharps, or for staff who did not have evidence of hepatitis B immunity.

The practice had ineffective systems to review and investigate incidents and accidents.

The practice had ineffective systems and processes for learning, quality assurance and continuous improvement. Audits of IPC, radiography, record keeping and antimicrobial prescribing did not contain accurate, sufficient information or documented learning points so resulting improvements could be demonstrated. The provider had not identified or responded appropriately where quality and safety were being compromised.

The practice did not have effective oversight of staff training. Prior to our assessment staff had not completed training in topics recommended by the GDC.

The practice was not managing concerns and complaints appropriately. A record of complaints was not available. A complaints policy was displayed, but this did not give clear information on how to raise a concern and did not comply with accessibility standards. The practice should improve the complaint handling procedures and establish an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.

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.