Wimpole Dental Office

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 31 January 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 14 July 2025, we found the practice had made the following improvements to comply with the regulation:

The provider demonstrated commitment to delivering safe, sustainable and high-quality care. They had engaged a compliance consultant to support their efforts in becoming compliant with legal and regulatory requirements. The provider also confirmed their intention to continue utilising external support to ensure adherence to the relevant health and safety, as well as premises safety legislation.

At the time of the follow up inspection the provider worked without chairside support. The majority of procedures offered by the service fell outside the scope of the Care Quality Commission’s (CQC) regulatory remit. The provider told us that only procedures currently falling within our remit were emergency dental appointments. The practice had an arrangement with the dental practice next door to provide support in the event of a medical emergency. We discussed with the provider the importance of ensuring that sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the requirements. In response to our inspection feedback, the provider stated that they had sought advice from their indemnity provider, who confirmed that under specific circumstances, such as unforeseen dental emergencies, it may be permissible to deliver dental treatment without chairside support. The provider also reassured us that recruitment was underway a dental nurse to support chairside assistance during non-emergency procedures.

Since our initial inspection on 31 January 2025, no new staff had been recruited. However, the provider had updated their recruitment policy to ensure it reflected the relevant legislation. The provider told us that, going forward, all necessary pre-employment documentation will be obtained at the point of employment. Additionally, structured induction programmes and annual appraisals were planned to support the professional development of new staff members.

Improvements had been implemented to ensure emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way.

A fire safety risk assessment had been carried out on 12 March 2025, and the recommendations made within the risk assessment had been fully implemented. These included maintaining an up-to-date fire logbook and creating a fire safety folder tailored solely for Wimpole Dental Office, used to record all fire safety activities, including weekly fire alarm tests and annual servicing. In addition, coordination with the landlord on fire safety matters has improved. This included obtaining documentation related to the servicing of the fire alarm control panel which displayed a fault light during the previous inspection and retaining copies of fire safety checks conducted within the building. The responsible person has completed fire awareness and fire marshal training.

The Electrical Installation Condition Report (EICR) was completed on 12 March 2025, confirming that the condition of the fixed electrical installations in the premises occupied by the practice was satisfactory, with no outstanding recommendations.

The practice had reviewed and updated its sharps risk assessment, which now clearly identified all types of sharps in use and outlined the specific safety measures implemented to mitigate associated risks.

A Legionella risk assessment had been carried out on 12 March 2025 and it covered Legionella safety measures within the parameters of the practice and included control measures specific to a dental setting. The recommendations made within the risk assessment had been fully implemented and a practice had a written scheme of control for water management in place. These included monthly hot and cold-water temperature checks, Legionella awareness training and undertaking external water analysis.

The practice had assessed the risks associated with lone working, the use of hazardous substances and handling sharps. Appropriate control measures were implemented for each area to mitigate risks.

A general health and safety risk assessment has been completed 12 March 2025, and all recommendations made within the risk assessment had been fully implemented. These included installing an emergency alarm with pull-cord in the toilet and the development of a written emergency evacuation plan tailored to the dental premises.

The practice ensured that all required radiation protection documentation was available and up to date. This included revised local rules, risk assessment, and a quality assurance plan to support the regular maintenance and timely servicing of radiological equipment. Outstanding actions from the radiological equipment survey report dated 16 March 2023 have been completed. This included registered work involving a radiation generator with the Health and Safety Executive (HSE) and securely fastening the tube head to the wall to ensure stable positioning.

The practice had conducted audits of radiography and antimicrobial prescribing, both of which included detailed analyses and accompanying action plans to support continuous improvement.

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.