Tolworth Rise 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 7 May 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.

Governance systems had improved and there was a system in place to ensure policies and procedures were reviewed on a regular basis. We noted that improvements made since our last inspection had become embedded in practice.

The practice had systems for recording significant events and incidents.

Improvements had been made to the oversight of equipment servicing. The principal dentist had created a document listing the due date for servicing of all equipment. This was available to all staff.

Improvements had been made to the management of hazardous substances. Substances were locked away and could no longer be accessed by patients. Access to the patient toilet was improved and the premises free from clutter.

Staff had completed risk assessments for substances used in the practice. These were kept in a folder alongside the safety data sheets, in a way that promoted easy access in an emergency.

Improvements had been made to the checking and logging of the medical emergency kit, which was now in line with national guidance. We saw evidence of weekly checks and a record of expiry dates for items in the kit. Further improvements should be made to include daily temperature checks of the fridge where emergency medication is stored. We were assured this would be implemented.

Improvements had been made to the management of fire safety. Staff were checking and logging fire equipment, including smoke alarms, fire extinguishers and emergency lighting. The emergency lighting had been serviced; however, the report highlighted an outstanding action which staff were not aware of. Following a discussion, we were assured they would address the recommendation.

Staff had participated in a fire drill since our last visit.

At our last visit, the provider could not demonstrate that the fire risk assessment had been completed by a competent person. No action had been taken since our last inspection. We discussed this with staff who confirmed a new fire risk assessment will be completed by the company who serviced their fire equipment.

We looked at 10 patient care records. Record keeping had improved since our last visit, however, further improvements were required. We recommended completing a record-keeping audit which would highlight areas for improvement.

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.