Trafalgar Woolston Also known as Smile Dental Care Group - Southampton

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 they have been put right by the provider.

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.

During our inspection of this key question, we found

the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found ineffective 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 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.

The provider’s oversight of regulatory requirements was ineffective. This assessment highlighted some issues and omissions relating to risk management, infection prevention and control, staff recruitment and quality assurance.

These shortfalls resulted in a failure to ensure that the necessary actions were taken to address the deficiencies identified in the practice's 2023 EICR and Legionella risk assessment reports, as well as ensuring the effective management of fire safety. Not all staff had the necessary evidence to support effective recruitment. Improvements were required to ensure that the decontamination of dental instruments was in line with national guidance.

Systems for auditing and continuous improvement required review. Radiography audits were not completed in line with current guidance. The disability access audit was not reflective of the practice and required review to ensure that the practice had considered, in full, reasonable adjustments.

We discussed with the leadership team that improvements should be made to the audit of antimicrobial prescribing and dental care records to ensure they would identify areas of improvement. In addition, the practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Staff feedback was obtained through meetings and informal discussions. Staff felt leaders in the practice were approachable and listened to their comments but were less sure this would result in meaningful change by the group.

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.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning within the practice. Further improvements were required to the oversight of complaints by the provider.

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

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.