Northwick Park 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 not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found:

the registered person had ineffective systems or processes to enable them to assess, monitor and improve the quality and safety of the services being provided

the registered person had ineffective systems or processes to enable them to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk

the registered person did not have effective systems to maintain records as are necessary to be kept in relation to persons employed

These concerns were in breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the detailed findings below.

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.

We found staff to be open to discussion and feedback. Where the assessment highlighted issues, the practice took some action to address these concerns immediately.

The information and evidence presented during the inspection was not clear or well documented.

We found that the provider had the values and commitment to deliver high quality sustainable services. However, the ineffective management of risks and the lack of effective oversight impacted the day-to-day management of the service.

The general health and safety risk assessment dated 3 March 2026 did not adequately consider key risk factors or accurately reflect the practice environment. For example, it referred to arrangements for dental laser protection and domiciliary care visits, although these services were not provided by the practice.

The document also stated that all staff members were up to date with their Hepatitis B vaccinations and that post–aerosol generating procedure downtime was observed when treating patients on respiratory pathways. However, these statements were not substantiated by our findings. Following the inspection the provider submitted an updated fire risk assessment dated 16 March 2026. We noted that this still included statements that did not accurately reflect the arrangements within the practice.

We also identified shortcomings in the management of risks associated with fire and Legionella.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.

The practice had some systems and processes for quality assurance and continuous improvement. This included undertaking audits according to recognised guidance in line with recognised guidance. Improvements could be made to ensure that audits were sufficiently robust to identify gaps in processes, including those relating to record keeping. In addition, further improvements were required to ensure that continuous learning was effectively supported through robust monitoring of training and regular appraisal of individual development needs.

The provider told us that concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. Examples included the implementation of improved systems for monitoring laboratory work, notifying patients of NHS fees in advance of their appointments, and displaying an informative video on periodontal disease in the waiting area.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, the practice aimed to reduce its environmental impact by using reusable instruments and recycling materials where possible. They ensured correct waste segregation andmainly usedigital systems instead of paper to reduce paper use. Staff also made sure that lights,computersand dental equipment were switched off at the end of the day to save energy.

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.