Chestnut Smile 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.

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 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 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. For example, the practice had implemented a more effective medicines log following feedback from staff. 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. The practice had taken steps to improve environmental sustainability. For example, the practice recycled where possible, used electronic tablet devices to reduce paper, used companies that aim to reduce their carbon footprint and turned off electrical appliances and lights when not in use.

Systems and processes were embedded, and staff worked together in such a way that where the assessment identified areas requiring improvements, these were acted on immediately. The information and evidence presented during the assessment was clear and well documented. 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). We saw there were clear and effective processes for identifying and managing risks, issues and performance. The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. The practice had systems for receiving and acting on patient safety alerts, recalls and rapid response reports. 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. Improvements should be made to ensure all templates are edited to reflect practice protocols. In particular, the freedom to speak up and infection prevention and control policies. We discussed this with staff and were assured this would be addressed. The practice should implement an effective system for recording, investigating and reviewing accidents, incidents and significant events with a view to preventing further occurrences and ensuring that improvements are made as a result. Although there was an accident book in place, there were no records of, or evidence of learning from incidents and accident. We were assured this would be addressed and recorded appropriately going forward.

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.