Smile Perfection

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. During our assessment of this key question, we found 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 were not effective. systems or processes to assess, monitor and improve the quality and safety of the services being provided were not effective. 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 report 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. The practice staff demonstrated a transparent and open culture. They were responsive to discussion and feedback to highlighted risks and took appropriate action to address these. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through informal discussions. Staff were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. For example, the staff suggested providing ladies sanitary products in the bathroom for staff and patients which the provider has implemented. Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they collected and responded to feedback from patients, the public and external partners. For example, following patient feedback, the practice adjusted their heating schedule to ensure a comfortable environment. The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible and turned off equipment and lights when not in use.

Improvements were required to some of the practice’s systems and processes to improve management oversight and assurance. The on-site assessment highlighted some issues and omissions. The practice’s governance system required improvements to ensure all documented policies, protocols and procedures were reflective of practice protocols. Improvements were required to the processes for identifying and managing risks, issues, and performance. In particular, the risks associated with fire and legionella. The practice’s systems and processes for learning, quality assurance and continuous improvement were not always effective. The practice undertook most audits according to recognised guidance, but did not formulate action plans to drive improvement. 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 paper records were stored securely and complied with General Data Protection Regulations (GDPR). The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

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.