Bursledon Dental Clinic

On this page

• Overview
• 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 breaches we found at our inspection on 23 November 2023 .

Find out what we look at when we assess this area in our information about our new Single assessment framework.

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.

At the assessment on 7 January 2025 we found the practice had made the following improvements to comply with the regulations: Staff told us the practice has taken steps to improve the governance and management of the practice, including implementing a recruitment policy; monitoring staff training through annual review of their continuing professional development; and applying for Disclosure and Barring Service (DBS) checks for staff who previously didn’t have evidence of appropriate checks. Training in subjects recommended by the General Dental Council (GDC) had been completed by staff. Staff told us a new fire risk assessment had been carried out by a suitably competent person and we saw that the identified actions from this had been completed. Staff described the improvements that had been made to the governance systems of reviewing their risk assessments, policies, procedures and protocols, including the Legionella risk assessment, and a clear review schedule was being followed. Following the assessment, we received evidence that appropriate vaccination records were now available. Feedback from staff was obtained through meetings and informal discussions. Meeting minutes were shared with staff unable to attend the meetings and staff appraisals had been completed. Improvements were ongoing to ensure meetings and communication are maintained regularly.

A new fire detection system was in place, and emergency lighting had also been installed. Improvements had been made to the tests and checks of the fire safety systems, which were now being carried out regularly, and in line with guidance. Some improvements were required to ensure all aspects of fire safety were being completed, for example a fire drill had not taken place since the installation of the new systems in June 2024. Emergency equipment and medicines were available and being checked in accordance with national guidance at the recommended intervals. The practice had taken action to improve the systems and processes for learning, quality assurance and continuous improvement. This included ensuring audits such as infection prevention and control were completed according to recognised guidance. The practice had improved their systems to review and investigate incidents and accidents. An incident log was in place and improvements were ongoing to ensure that a General Data Protection Regulation (GDPR) compliant accident book was available and used correctly. The practice had improved their processes for managing risks, issues and performance. For example, we saw evidence that complaints were managed and recorded appropriately.

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.