Smilecare Dental Centre

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 the registered person had systems or processes that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular, risks relating to clinical records, the completion of audits and the governance arrangements to support staff with their roles. 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. The practice provider demonstrated a transparent and open culture in relation to people’s safety and demonstrated they had taken onboard feedback related to the identified shortfalls. Staff told us there was strong leadership with emphasis on continually striving to improve clinical care. Staff understood their responsibilities and roles, but improvements were required to the systems of accountability to support good governance and management. Feedback from staff was obtained through meetings and 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. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff told us how they collected and responded to feedback from patients. For example, through the use of patient comments and online feedback which was responded to.

Systems and processes to support good governance required timely review. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff. However, these required updating. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), but the practice did not display a privacy notice showing that CCTV is in operation. Following the assessment a notice was displayed. We saw the processes for identifying and managing risks, issues and performance required review. Staff were not aware of College of General Dentistry Guidelines on antimicrobial prescribing. Clinical records were difficult to access, frequently illegible and did not take into account current guidance. The practice had some systems to review and investigate incidents and accidents, and for receiving safety alerts. The practice responded to concerns and complaints appropriately. The practice systems and processes for learning, quality assurance and continuous improvement required review. For example, audits were not completed in line with guidance. Where the assessment identified areas which required improvement, we received assurances that these would be acted on. We were told of plans to improve and of the new support systems which would be implemented.

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.