Holloway House 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 not providing well led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider made insufficient improvements to putrightthe shortfalls and had not responded to the regulatory breach we found at our inspection on 6 January 2026.

We have told the provider to act.We will be following up on our concerns to ensure the provider has made the required improvements.

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.

At the inspection on18 August 2026,we found the practice had made the following improvements to comply with the regulation:

Local rules included the handheld x-ray machine.
The handheld x-ray machine had a rectangular collimator.
Annual servicing documents were available for the wall-mounted and handheld x-ray machines.
Annual performance testing of the handheld x-ray machine was evident.
A radiation risk assessment for the Cone Beam Computed Tomography (CBCT) x-ray machine was evident.
Quality assurance (QA) testing evidence for the CBCT was available.

The practice’s ultrasonic bath was present in the decontamination room. We were told the bath was not in use. The practice was able to demonstrate that the ultrasonic bath had been serviced appropriately.
The practice was able to demonstrate that the autoclaves had been serviced appropriately.

The practice’s washer disinfector was present in the decontamination room. We were told the washer disinfector was not in use. The practice was able to demonstrate that the washer disinfector had been serviced appropriately.
The practice was able to demonstrate that the compressor had been serviced appropriately.
The practice had an external Legionella risk assessment carried out in June 2026. We will verify that the action has plan has been completed at our next visit.

Language interpreter and translation services were available.
A ground floor treatment room was overlooked by a pavement. Window coverings were in place to protect the patients’ privacy.

The patient complaints procedure was on display in the patient waiting area. The procedure consisted of a number of pages. Patients were unable to remove pages due to them being in a plastic sleeve which was attached to a notice board. Improvements should be made to enable patients to read the complete complaints procedure document independently
Patient surveys were collated and findings analysed.

Radiography audits were carried out in line with current guidance and legislation.
The most recent infection prevention and control audit reflected current practice.

Closed circuit television (CCTV) warning signage was prominent.
A CCTV privacy impact assessment was available.
Information for patients was available to explain the purpose of recording images.
The name and contact details of those operating the surveillance scheme were displayed.

Completed accident records were stored securely.

We found a number of additional shortfalls:

Patient identifiable information was disposed into a waste bin in treatment room 1.

Since our previous inspection, 3 new staff were employed. We reviewed their recruitment and training records and found,
A full employment history was not present for 2 staff.
A health assessment was not present for 2 staff.
The reason for leaving the last job was not present for 1 member of staff.
Conduct in previous employment (reference) was not present for 1 member of staff.
Five hours of radiography continuing professional development (CPD), carried out in the previous 5 years, was not present for 1 clinician.

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.