Pitsmoor Dental Health 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 providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance. The provider had made improvements in relation to the regulatory breach we found at our inspection on 6 March 2024.

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.

During the assessment we found staff to be open to discussion and feedback. The practice staff and provider demonstrated a transparent and open culture in relation to people’s safety. Staff told us improvements had been made to ensure there was strong leadership with emphasis on people’s safety and continually striving to improve. Staff told us arrangements had been put in place to ensure they had clear responsibilities, roles and systems of accountability to support good governance and management. Staff stated they felt respected, supported and valued. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. Staff told us how they kept up to date with current evidence-based practice.

The information and evidence presented during the assessment process was clear and well documented. The practice was in the process of embedding governance systems which included policies, protocols and procedures that are accessible to all members of staff. We saw there were clear and effective processes for identifying and managing risks, issues and performance. The practice had improved systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We discussed with the provider the importance of regular audits to maintain current standards.

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.