Southbrook 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.

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 5 June 2026, we found the practice had made significant improvements to be compliant with the regulations.

The practice staff demonstrated an honest attitude towards the inspection process and were open to discussion and feedback, and the issues identified.

Systems and processes had been established to ensure the risks associated with the carrying on of the regulated activities were appropriately managed. Risk assessments for health and safety, and hazardous substances had been completed. Staff had clear responsibilities, and systems of accountability to support good governance.

The recruitment policy was now being followed. Staff files were complete and held securely.

The practice now had effective processes to support and develop staff and ensure their training was up-to-date. We saw completed induction checklists for new staff.

We looked at a selection of patient care records. Improvements had been made to the quality and detail recorded within patient care records. There were details recorded of risk assessments, a diagnosis and oral hygiene advice provided. We also noted that antimicrobial use was now justified within the patient care records. X-rays were taken as identified in nationally recognised guidance; however, these were not always fully reported on. In addition, we noted in some records there was an indication that a periodontal screening had been carried out, however, the results of this screening had not been recorded within the patient care records. We discussed these issues with the provider and were assured further improvements would be made.

There was oversight and auditing of infection prevention and control procedures and hand hygiene.

Although there had not been a full cycle of audits of radiography, antimicrobial prescribing and dental care records, data collection for these had commenced and some themes had already been identified. We were assured that the full audit cycle would be completed and actions plans would be developed and implemented.

Improvements had been made to the system for identifying and managing the risk associated with the carrying out of the regulated activities.

Improvements had been made to the system for managing the risks associated with fire. We saw evidence that actions arising from the fire risk assessment carried out on 26 June 2025 had been addressed. We also saw evidence of regular checks on fire detection and firefighting equipment. We were assured this new system would become fully embedded.

Improvements had been made to the system for managing the risks associated with Legionella, or other bacteria, developing in water systems, in line with a risk assessment. These included monthly water temperate checks from sentinel outlets, the appropriate management of the dental unit water lines and for cleaning the water filter system. In addition, staff had attended Legionella awareness training.

The workflow in the decontamination room had been reviewed and clear procedures were in place to ensure this was followed consistently. There were processes for ensuring staff carried out validation checks on equipment and saved evidence of completed sterilisation cycles.

In addition, a review of disability access had been carried out and an emergency pull cord had been installed in the patient toilet.

The policy and privacy impact assessment were now in place for the use of closed-circuit television (CCTV).

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.