Broadway 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.

Staff had clear responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, surveys, appraisals and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

Feedback from patients, the public and external partners was collected to which the practice responded.

The practice had taken steps to improve environmental sustainability. For example, recycling and turning off equipment and lights where possible.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.



There were processes for identifying and managing risks. We found staff were open to discussion and feedback, and staff worked together in such a way that where the assessment identified minor areas of risk which required improvement, these were acted on immediately.

The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records. However, we noted some computers left logged in and unattended. We discussed this with staff and were assured this would be addressed.

The practice had installed closed-circuit television (CCTV) to improve security for patients and staff. Relevant policies and protocols were in place for the use of closed-circuit television (CCTV).

However, we noted a Data Protection Impact Assessment (DPIA) had not been carried out to assess the purpose, necessity, and risks prior to installation of CCTV. Following the on-site assessment, the practice sent evidence that a DPIA had been completed.

Improvements should be made to ensure all follow-up actions from incidents and accidents are documented and to systems to ensure the practice are receiving and acting on safety alerts. We discussed this with management and were assured this would be addressed.

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.