The 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.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 13 November 2025.

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 systems in place for the management of fire safety across the premises. A comprehensive fire safety risk assessment was undertaken on 4 December 2025 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. Fire exits were fitted with thumb-turn locks to ensure they were immediately openable, and both emergency escape lighting and an interlinked fire detection and alarm system had been installed. Improvements were also noted in the management of trailing leads and adapters, and flammable substances were stored appropriately.

The practice had improved procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment carried out on 5 November 2025. The responsible person had undertaken appropriate training and ensured all actions identified within the risk assessment were duly completed and ongoing control measures carried out as required.

The practice had improved arrangements to ensure the safety of its X-ray equipment, in particular the cone-beam computed tomography (CBCT) unit. The CBCT equipment had received a routine performance test on 26 November 2025, and the practice manager confirmed that this would be carried out annually going forward.

The practice recruitment policy and procedures reflected relevant legislation and the required recruitment documentation, including vaccination records and Disclosure and Barring Service (DBS) certificates, were available for every member of staff.

The practice had implemented improved arrangements to ensure staff training was up-to-date and reviewed at the required intervals. The system used by the practice enabled management to track the completion of mandatory training and to identify any outstanding learning requirements. All members of staff had completed training modules relevant to their role.

Staff had carried out an improved disability access audit and had an action plan to continually improve access for patients. A portable ramp had been obtained to facilitate access for wheelchair users and arrangements to obtain reading glasses had been made for those with sight difficulties. The practice manager confirmed that language translation services would be arranged should the need arise. Other mandatory audits were carried out in a meaningful manner with documented learning points. The practice should implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.

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. The whistleblowing policy had been updated to ensure staff knew how to raise concerns to external agencies if they felt unable to do so internally.

The information and evidence presented during the assessment was clear and well documented.

The practice had also made further improvements:

The practice had improved their systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

Radiographic images taken with the CBCT equipment were evaluated using the full dataset and findings were recorded in detail, in accordance with legal requirements.

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.