The York Dental Suite

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, 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. One staff member had registered interest in learning basic British Sign Language and the practice were facilitating this training. 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, they were working towards being paperless. The practice was in the process of arranging visits to local care homes to take residents to church, to participate in arts and crafts activities and to volunteer with befriending. The practice is also registered with the local council as volunteer litter pickers.

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. 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). This included the use of tablets to enable patients to complete medical histories. 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. Staff discussed outcomes to share learning and improve the service. We saw there were clear processes for identifying and managing risks, issues and performance. Systems and processes were mostly embedded. However, our assessment highlighted some issues or omissions, which meant systems and processes were not always working effectively. For example, there were some gaps noted in staff files and with staff training compliance. The practice’s systems and processes for learning, quality assurance and continuous improvement were not always effective. The practice carried out most required audits according to recognised guidance. However, the required radiography audit had not been completed. There was also no evidence of completed actions and shared learning from the required audits that had been completed. We raised this with staff and were assured this would be implemented going forward. Relevant policies and protocols were in place for the use of closed-circuit television. However, a Data Protection Impact Assessment had not been completed. We raised this with staff and were assured that this would be completed.

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.