The 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.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 28 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.

At the inspection on 23 September 2026, we found the practice had made the following improvements to comply with the regulation:

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

Improvements had been made to the systems and processes for learning, quality assurance and continuous improvement, including undertaking audits of radiography, infection protection and control and antimicrobial prescribing at the require intervals. Audits had been improved to include documented learning points.

The practice’s complaints process had been reviewed and updated to include the practice details and was now accessible to patients. A monitoring system to track complaints had also been implemented.

The practice had introduced an effective system for tracking referrals, which was accessible from all of the practice’s computer desktops.

The practice’s system and process for identifying and managing risk in relation to fire safety and lone working had been improved. For example, a new fire risk assessment had been carried out and the actions within this completed. In addition, a lone worker risk assessment had also been carried out.

Medical emergency equipment and medicines were checked in line with guidance. However, some improvement was still required to assure the effectiveness of these checks as we found 2 items had expired, which had not been identified. This was addressed immediately.

The practice had made some improvements to the system for ensuring the safety of the X-ray equipment and the required radiation protection information was available. However, 1 x-ray unit’s 3 yearly performance check was overdue. We saw evidence that this was addressed immediately and testing was arranged.

Improvements had been made to ensure current safeguarding information was available, and staff were in the process of finalising completion of appropriate training.

The practice had arrangements to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. We saw that staff had completed training in all CPD relevant to their roles as recommended by the General Dental Council (GDC).

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A new Legionella risk assessment had been carried out and recommendations within this had all been actioned, including insulating pipes to maintain temperatures within the appropriate range.

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.