Mr C Carre BDS Dental 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.

At the assessment on 28 June 2024 we found the practice had made the following improvements to comply with the regulation: The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals. The provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice, and the reporting of risks was encouraged. A fire safety risk assessment was carried out in line with the legal requirements. The management of fire safety was effective. The practice had systems for appropriate and safe handling of medicines. We found staff to be open to discussion and feedback. The practice staff demonstrated a transparent and open culture in relation to people’s safety. Staff told us there was strong leadership with emphasis on people’s safety and continually striving to improve. Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management. Feedback from staff was obtained through meetings, surveys, 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. 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, they used the NHS Friends and Family test to gather feedback from their patients.

At the assessment on 28 June 2024 we found the practice had made the following improvements to comply with the regulation: The practice had infection control procedures which reflected published guidance and the equipment in use. Staff had appropriate training, and the practice completed Infection prevention and control (IPC) audits in line with current guidance. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. The information recorded in patient care records was mostly in line with recognised guidance, however we noted periodontal charting, social history and risks for oral cancer and tooth wear were not always recorded in the patient care records. Staff obtained patients’ consent to care and treatment in line with legislation and guidance. They understood their responsibilities under the Mental Capacity Act 2005. Systems and processes were embedded, and staff worked together in such a way that the assessment did not highlight any issues or omissions. The information and evidence presented during the assessment was clear and well documented. The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis. We saw there were clear and effective processes for identifying and managing risks, issues and performance. 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. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

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.