Egremont Smile Centre

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 25 April 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.

At the inspection on 21 October 2025, we found the practice had made the following improvements to comply with the regulation:

We saw that clinical waste was adequately stored and no longer accessible to unauthorised persons.

Systems had been reviewed to ensure staff carried out the decontamination of used dental instruments in line with the Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM01-05). Additional training protocols had been introduced to support ongoing adherence to the guidance.

The systems for managing and overseeing procedures to reduce the risk of Legionella had also been reviewed. A new risk assessment had been completed, and we were told all recommendations had been actioned. Ongoing temperature monitoring was in place, and a task-based reminder system had been introduced to ensure this continued.

A new system had been introduced to ensure equipment was serviced and maintained according to manufacturers’ guidelines. The practice manager was confident that this improved oversight would help prevent any missed servicing.

We reviewed the current recruitment checks for new staff and found them to be effective overall. Required documents were requested before the staff member started work. Risk assessments were carried out where there were delays in receiving documents, such as Disclosure and Barring Service (DBS) certificates.

Protocols had been introduced to support staff in monitoring key training records. While this work was still ongoing and some gaps remained at the time of our visit, the practice manager was confident the new systems would lead to sustained improvements.

Auditing protocols had been reviewed and updated, with the team actively working to ensure all dental care records consistently included essential information, in line with current guidance. Where gaps were found, action plans were created, and additional training was recommended. This work is ongoing, and some areas still require further attention to consistently meet the minimum standards expected.

Additional auditing protocols had been introduced to improve the monitoring of prescriptions. However, these were not yet fully effective at the time of our visit, and further work was needed to ensure all prescriptions could be consistently accounted for.

The practice had also made further improvements:

Since our last visit, a new fire risk assessment had been completed, and action had been taken to address the recommendations.

The team had also provided further training to staff on the safe handling and storage of hazardous substances. Risk assessments related to hazardous substances had been reviewed and were accessible to staff.

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.