Bayston Hill 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.

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 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 sometimes listened to and acted upon, where appropriate. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities within their capabilities. Staff told us how they collected and responded to feedback from patients, the public and external partners.

Where the assessment identified areas which required improvement these were acted on immediately. The information and evidence presented during the assessment was clear and well documented. 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. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV) We saw there were clear and effective processes for identifying and managing risks, issues and performance. 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. The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance. We found the radiography audits were carried out annually rather than the recommended 6 monthly and they were not of a sufficient sample size or clinician specific. The infection prevention and control audits were also carried out annually rather than the recommended 6 monthly. The antimicrobial prescribing audits were not clinician specific.

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.