Chingford Road Dental Surgery

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.

The practice responded to concerns and complaints appropriately. Staff discussed outcomes to share learning and improve the service.

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 welcomed feedback from patients, the public and external partners.

The practice had taken steps to improve environmental sustainability. For example, the provider had installed infra-red heating, and hot water was now provided via a hot water heating tank. Most patient recording systems were digital including X-ray and record keeping.

Most systems and processes were embedded. The inspection highlighted some issues and omissions, most of which the provider had taken steps to resolve satisfactorily.

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. However, the information and evidence presented during the assessment was not always clear and well documented. Some governance arrangements needed strengthening to ensure that the availability and checking process of emergency equipment were robust, that recruitment checks aligned with Schedule 3 of the Health and Social Care Act (Regulated Activities) Regulations 2014 as per the practice policy and that records were maintained for fire evacuation drills and monitoring of fridge temperature.

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 minimal paper records were stored securely and complied with General Data Protection Regulations (GDPR).

We saw there were processes for identifying and managing most risks, issues and performance.

The practice had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts.

We found improvements were required to the systems and processes for learning, quality assurance and continuous improvement. At the time of the inspection the provider did not have evidence to demonstrate they undertook continuous audits of patient care records, and infection prevention and control. Whilst we saw a copy of a good record keeping audit, it was dated 2012 and therefore not current.

We noted innovative approaches to providing person centred care. For example, we saw evidence of peer learning by the provider who worked in other clinical settings to develop their skills and knowledge.

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.