Cedar House Orthodontic 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.

Systems and processes were embedded, and the inspection did not highlight any significant issues or omissions. 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 paper records were stored securely and complied with General Data Protection Regulations.

There were effective processes for identifying and managing risks, including sepsis and lone working.

Improvements should be made to the processes and systems for investigating incidents. In particular, ensuring all follow-up actions from incidents and accidents are documented with evidence of reflection and shared learning. We discussed this with staff and were assured this would be addressed.

Improvements should be made to the systems for receiving and acting on patient safety alerts. We discussed this with staff and the practice signed up to receive patient safety alerts on the day of inspection.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

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.

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, making changes to the staffing rotas following staff feedback.

The practice gathered feedback from patients, the public and external partners, and responded accordingly. For example, making changes to how some medical history questions were phrased following patient feedback.

The practice had taken steps to improve environmental sustainability. For example, recycling where possible, turning electrical devices and lights off when not in use, ordering less to reduce deliveries, and swapping to digital communications to reduce on paper and postage.

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.