Woodlands Orthodontics

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• 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 30 October 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.

Systems and processes in place were now effective at identifying and managing risks, including medical emergencies and fire safety.

Leaders told us they were in the process of formalising governance arrangements to support the development of a culture of continuous improvement.

Staff could now access emergency equipment and medicines and improvements had been made to ensure these were checked weekly in line with national guidance. We saw that the provider had purchased a new AED equipment and defibrillator pads were all in date at the time of our inspection.

Improvements had been made to ensure the radiation protection information was available, including bespoke local rules. At the previous inspection, there was no evidence that the X-ray machines had received annual electro-mechanical servicing. At the inspection on 19 March, we found this had been rectified.

Improvements had been made to the management of fire safety. A risk assessment had been carried out on 22 December 2025. Most recommendations had been actioned, some were still in progress. The smoke detectors were deemed insufficient for a commercial building. The practice was in the process of obtaining quotes for a new fire alarm system. Staff now conducted and documented in-house checks of the smoke detectors, however, these were monthly rather than weekly as required by The Regulatory Reform (Fire Safety) Order 2005. We discussed this with the provider and were assured this will be addressed.

Staff had started documenting their in-house checks of fire extinguishers. The emergency lighting was serviced on 27 January 2026 and was found to not be working. We saw evidence that a new emergency lighting system would be installed on 14 April 2026.

Since our last inspection, we have received satisfactory records of servicing and validation of all equipment in line with manufacturer’s instructions. We saw evidence of a scheduling system the practice has implemented to ensure that future servicing is completed on time and not missed.

Previously, there was no evidence of current or historical Electrical Installation Condition Reports (EICR). The provider had an EICR carried out on the 28 January 2026. The report concluded that the safety and condition of electrical installations in the practice was unsatisfactory. The remedial work had been completed recently, and we will be following up on the new report.

The practice had a governance system that included policies and procedures, which were accessible to staff. Policies had been reviewed and updated, ensuring they were reflective of practice processes. Staff had implemented a scheduling system which would send out reminders when policies were due for review.

Improvements had been made to the systems and processes for learning, quality assurance and continuous improvement. We found that audits were now undertaken according to recognised guidance with action points addressed and shared with the wider team for learning.

Previously, the practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. There were 4 recommendations on the risk assessment dated 12 August 2025, none of which had been actioned including 1 classed as ‘urgent’. These recommendations had still not been actioned; however, the engineer had been booked to complete the work on 14 April 2026. We will be following up with the practice to ensure this has been completed.

The practice had closed-circuit television cameras, however, a data protection impact assessment (DPIA) had not been completed to identify and mitigate any risks to personal data. We discussed this with the practice and were assured one would be completed. Improvements were also required to signage alerting patients and members of the public to the use of recording equipment.

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.