Welwyn 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 20 November 2024.

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 29 July 2025 we found the practice had made the following improvements to comply with the regulation:

The practice’s governance arrangements had improved to ensure sustainability in the longer term.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises.

Improvement had been made to infection control and prevention processes, in particular regarding the transportation of dirty instruments and instrument storage which was now in line with guidance.

Medicines and equipment for the management of medical emergencies were available and in date in line with UK Resuscitation Council UK guidance. Weekly checks of the emergency medicines were completed although improvements could be made to include emergency equipment in these checks.

A thermometer had been obtained to monitor the fridge temperature to ensure that glucagon (a medicine used to manage low blood sugar) was stored according to manufacturer’s recommendations.

Improvements had been made to identify and mitigate the risks associated with fire. A fire risk assessment, and an electrical installation condition report had been completed. We saw that emergency lighting had been installed, and periodic in-house testing of the smoke alarms and emergency lighting had been implemented. Fire evacuation drills were also being carried out.

The practice now had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

Regular water temperature and quality checks were being completed to mitigate the risks associated with Legionella and other bacteria developing in water systems.

Infection prevention and control and radiography audits were completed in line with guidance.

Practice policies had been updated to be practice specific and reflected current guidance.

The health and safety and sharps risk assessments reflected the practice processes and actions had been taken to mitigate the risks identified, including lone working and the replacement of a damaged carpet.

A disability access audit had been completed.

Staff were provided with training that was appropriate for their role.

The provider signed up to receive patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency.

The practice had not recruited any new staff since the last inspection. However, recruitment procedures had been strengthened and a recruitment policy which reflected current legislation, and an induction check list had been obtained. Further improvement could be made to ensure that all staff had evidence of immunity to Hepatitis B.

The practice had also made further improvements:

Record keeping and antimicrobial prescribing audits had been completed.

Staff were provided with an appraisal and formalised staff meetings were undertaken.

Additional colour coded equipment for environmental cleaning had been obtained in line with British Institute of Cleaning Science (BICSc) guidance.

The clinical waste container was now secured.

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.