Portland Street Dental Care

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• 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 29 January 2026.

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.

The provider had made improvements to the management of risks. This included sharps safety, sepsis awareness and lone working. In particular, contaminated sharps would only be dismantled and disposed of by the administering clinician. The provider should ensure that the rationale for not using a safer sharps system for needles is documented. The lone working policy was reviewed and measures were put in place to ensure the safety of lone workers.

The provider had improved the systems and procedures for monitoring the medicines and equipment used in the event of a medical emergency, taking into account relevant guidance. Following our comprehensive inspection on 29 January 2026, we were provided with evidence that all missing items had been replenished. At this follow-up inspection we were assured that emergency medicines and equipment were checked weekly to ensure ongoing compliance and safety for patients.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. In particular, the compressor had been serviced and inspected in accordance with the written scheme of examination as required by the Pressure Systems Safety Regulations 2000 on 4 March 2026.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. The provider was registered with Health and Safety Executive (HSE) for working with ionising radiation and all overdue maintenance and quality assurance tests had been completed between 27 January and 4 March 2026.

The provider had made improvements to the systems in place for the management of fire safety across the premises. A comprehensive fire safety risk assessment was undertaken on 6 March 2026 by a competent person. The fire risk assessment identified a number of recommendations to ensure compliance with fire safety legislation within the premises. All recommendations had been fully implemented, and both emergency escape lighting and improved signage had been installed. Improvements were also noted in the management of electrical socket adapters, and combustibles were stored appropriately. Fire escape routes were clear and the external waste bin was relocated to reduce arson risk. Fire drills and fire safety training had been carried out. Fire safety checks were logged appropriately.

The practice had systems for appropriate and safe management of medicines. In particular, dispensed medicines were labelled an accordance with In particular by ensuring dispensed medicines were labelled in accordance with the Human Medicines Regulations 2012.

The practice recruitment policy and procedures reflected relevant legislation and the required recruitment documentation, were available for every member of staff. The provider understood the information required in respect of persons employed as described in Schedule 3 of the Health and Social Care Act 2008 Regulated Activities Regulations 2014.

The practice implemented improved arrangements to ensure that staff training was up to date and reviewed at the required intervals. The system in place enabled effective monitoring of mandatory training completion and allowed management to identify and address any outstanding learning needs. All staff had completed safeguarding training appropriate to their roles. They demonstrated a good understanding of safeguarding principles and were aware of how to access relevant information. Staff were also knowledgeable about the processes for escalating safeguarding concerns both within the practice and to external agencies. However, further improvements were required to ensure that all self-employed staff provided the practice manager with evidence of completed training, in line with the practice policy.

The practice had infection control procedures that reflected published guidance. Improvements had been made to clearly define dirty and clean zones within the treatment rooms. New instrument transportation boxes were purchased to transport contaminated and sterilized instruments separately to and from the decontamination room. The provider had implemented systems to ensure infection prevention and control audits were carried out in line with current guidance in order to identify where improvements could be made.

The Legionella risk assessment had been reviewed and the recommended actions had been implemented. The duty holder and staff had completed Legionella training.

Improved systems and processes had been developed and implemented, and staff worked together in such a way that the inspection did not highlight significant issues or omissions.

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. Improvements were made to ensure that information and guidance on how to raise a complaint were readily available and accessible to all patients using the service. In addition, systems were established to ensure that mandatory audits were conducted at regular intervals, in line with current guidance and relevant legislation.

The practice had also made further improvements:

The principal dentist completed additional training to enhance antimicrobial prescribing practices. Following this, a review of current prescribing was undertaken, which identified instances where national guidance was not being fully adhered to. As a result, prescribing habits were revised where necessary. In cases where prescribing deviated from guidance, clear clinical justification was documented in the patient records to support decision-making.

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.