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 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 March 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 19 October 2026, we found the practice had made the following improvements to comply with the regulations:

During the inspection we found staff to be open to discussion and feedback.

The practice staff demonstrated a transparent and open culture in relation to people’s safety. The provider showed a clear commitment to delivering safe, sustainable and high-quality care. Findings from the previous inspection had been discussed during team meetings, and there was clear evidence that staff had worked collaboratively to address the identified issues and implement the required improvements.

To support ongoing development and strengthen governance arrangements, the practice used a compliance portal to ensure that all governance processes aligned with relevant regulatory requirements.

An annual compliance planner was in place, incorporating scheduled policy reviews, risk assessment updates, audits and staff appraisals. We saw evidence that monthly meetings were held to review relevant sector-specific regulations and guidance, monitor progress against compliance requirements and achievements and review progress towards the practice’s goals.

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

Improved systems and processes had been developed and effectively implemented. Staff worked together in such a way that the follow up inspection did not highlight any significant issues or omissions.

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 by a competent person on 18 March 2026. The risk assessment included all requirements as outlined in the relevant guidance and legislation, such as the overall size and layout of the premises, the adequacy of fire detection and warning systems, staff fire safety training, and the specific needs of vulnerable people, including those with mobility difficulties.

The risk assessment identified a number of recommendations to further enhance fire safety arrangements. Evidence was reviewed confirming that the majority of recommendations had been fully implemented. Personal Emergency Evacuation Plans had been developed for all disabled persons using the premises, and the fire safety logbook and maintenance records were being maintained and kept up to date. The fire safety policy had been reviewed to support ongoing development and continuous improvement. Staff had received appropriate training in the use of fire extinguishers, fire drills were conducted at least annually, smoke detectors and fire alarm systems were tested weekly, and fixed electrical installation testing was undertaken at five-yearly intervals. The required fire doors had been ordered, with arrangements in place for their installation to be completed before the end of November 2026. In addition, improvements had been made to the systems for ensuring effective co-operation and co-ordination between duty holders in relation to fire safety matters.

Systems for identifying, assessing, and mitigating risks associated with Legionella and the growth of other harmful bacteria within the water systems had been strengthened. Evidence confirmed that the medium- and high-risk recommendations identified in the Legionella risk assessment dated November 2025 had been actioned. These included formally documenting the statutory duty holder and responsible person; implementing a system for regular monitoring of the control measures; ensuring those appointed to carry out the Legionella control measures were suitably informed, instructed and trained; producing an up-to-date schematic diagram of the layout of the water system and developing a Legionella scheme of control. In addition, issues relating to poor water system performance had been investigated and addressed through the installation of water heaters and the implementation of monthly hot- and cold-water temperature monitoring to support the ongoing effectiveness of the control measures.

The practice had reviewed their general health and safety risks assessments, which now incorporated practice-specific information and identified appropriate control measures.

The practice had implemented effective systems to ensure that all equipment remained safe, functional and maintained in accordance with relevant regulatory requirements and manufacturers’ recommendations. A comprehensive equipment servicing schedule had been established, supported by a planned preventative maintenance system covering all clinical equipment, including the air compressor. In addition, a servicing log and reminder system had been introduced to monitor maintenance requirements, track servicing activities and ensure that routine maintenance was completed within the required timescales.

Systems for centrally monitoring staff recruitment had been strengthened, and the required recruitment documentation was available in accordance with Schedule 3 of the Health and Social Care Act 2008. Risk assessments had also been completed for staff members awaiting blood test results to confirm their response to the Hepatitis B vaccination. The provider confirmed that, going forward, all required recruitment documentation would be obtained and verified at the point of employment. This would include a complete employment history, recent photographic identification, and satisfactory evidence of conduct in previous employment, supporting compliance with recruitment requirements and strengthening the provider’s employment verification processes.

The practice had implemented improved arrangements to ensure staff training was up-to-date and reviewed at the required intervals. The practice had subscribed to a training portal, providing staff with access to a range of learning modules. A dashboard was available through the portal, enabling management to track the completion of core training and to identify any outstanding learning requirements. We saw evidence that all staff had completed the required core training, as well as additional training relevant to their individual roles.

The practice had strengthened its audit processes to ensure they effectively identified areas for improvement, highlighted gaps in compliance and supported the implementation of appropriate actions to address identified issues.

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.