Boulevard Dental Surgery

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 provider 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 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. Staff told us how they collected and responded to feedback from patients, the public and external partners.

Systems and processes were embedded. 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. We saw there were processes for identifying and managing risks, issues and performance. Where the assessment highlighted some additional areas of risk, staff were open to feedback. We were assured these would be addressed and rectified. There were systems for receiving and acting on safety alerts. The practice should implement an effective system for recording, investigating and reviewing accidents, incidents and significant events with a view to preventing further occurrences and ensuring that improvements are made as a result. In particular, we saw 2 documented sharps injuries in the accident book. There was no evidence either had been followed up or investigated to prevent re-occurrence. 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 signposted the provider to nationally agreed audit tools to support their processes.

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.