Ellesmere 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.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis. Systems and processes were embedded, and the assessment did not highlight any significant issues or omissions. Areas requiring improvement were acted on immediately. 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. The doors in the reception area could be closed to enable confidential conversations. There were effective processes for undertaking audits, identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts. The radiography audit target was too low, the sample size did not meet guidance and was not completely 6 monthly. We discussed this with the practice principals and were assured this would be rectified. The practice should take action to ensure audits of radiography are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points, and the resulting improvements can be demonstrated. Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We noted innovative approaches to providing person centred care. Clinipads (electronic devices) were used for patients to complete documents, for example their consent forms and medical histories. Staff demonstrated an open culture in relation to people’s safety. Staff had clear responsibilities, and systems of accountability to support good governance. Staff feedback was obtained through meetings, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Feedback from patients, the public and external partners was collected and responded to. The practice had taken steps to improve environmental sustainability. For example, the practice was 99% paperless, all medical histories were completed before attending the practice (a clinipad was used onsite), 2 members of staff have electric cars, 2 members of staff cycle to work. There are LED lights in the hallway, and they recycle all paper and cardboard.

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.