Court Drive 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. The provider had made improvements in relation to the regulatory breach we found at our inspection on 15 March 2024.

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.

Staff were open to feedback and demonstrated a transparent and open culture in relation to people’s safety. Staff 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. Staff said that ‘Leaders are available and hands on when it comes to help and support’. Staff also commented that they felt ‘comfortable and confident raising concerns’ and they had ‘no doubt that those would be listed to and addressed appropriately’. Staff stated they felt respected, supported and valued. One staff member told us, ‘I feel very happy working here. I feel supported and looked after and I feel that my personal and professional development is also encouraged and supported’. The new practice manager told us that they had an open-door policy and staff were invited to discuss any concerns with them. We were told that since they joined, there was more consistent oversight and staff felt more supported. The practice manager told us that they now had systems in place for effective communication and information sharing. We were told that the practice had regular meetings with a set agenda and updated policies and practice documents were shared with staff effectively. The practice manager showed commitment to meet the legal requirements and a willingness to act on feedback. We were assured that they were in the process of establishing a robust compliance and governance system. Staff told us how they collected and responded to feedback from patients. This included encouraging patients to give feedback through their digital software package. The practice had taken steps to improve environmental sustainability. They segregated waste and strived to be paper-free.

At the assessment on 16 August 2024 we found the practice had made the following improvements to comply with the regulation: Improvements had been made to ensure systems in place for the management of risks associated with fire were effective. The practice had upgraded the fire alarm system, call points with relevant signage and a new emergency lighting system had been installed. There were systems in place for the periodic in-house testing of the fire safety equipment. The practice had made improvements to ensure arrangements in place for the safe use of X-ray equipment were effective. We were shown evidence that the cone-beam computed tomography (CBCT) machine and the intra-oral units received 3-yearly performance surveys on 30 April 2024. Following the inspection the practice submitted their CBCT Quality Assurance Policy and the relevant documents used as part of their CBCT quality assurance programme. Improvements have been made to ensure the practice recruitment procedures reflected the relevant legislation. The practice had employed an associate dentist since the last inspection, and we saw evidence that the required recruitment documentation had been obtained at the point of employment. The practice manager uploaded all staff recruitment documentation to a compliance portal and we were told that this will provide easier access to documents and more streamlined monitoring. We were shown evidence to demonstrate that recommendations made in the Electrical Installation Condition Report and Gas Safety Certificate dated 5 December 2023 had been completed. Improvements had been made to ensure that training and learning development needs of individual staff members were met and reviewed at regular intervals. The practice now had an effective system in place for monitoring staff training to ensure overdue training can be swiftly identified. We were shown records to demonstrate that individual training needs had been discussed with staff during annual appraisals.

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.