The Elms 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 breaches we found at our inspection on 28 May 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.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises.Staff told us they had clear responsibilities, roles and systems of accountability to support good governance and management.

Systems and processes were embedded, and staff worked together in such a way that the follow up inspection did not highlight any significant issues or omissions.The information and evidence presented during the inspection was clear and well documented. The practice now had an effective governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis.

The practice now had systems to review and investigate incidents and accidents, and for receiving and acting on safety alerts. We saw specific policies for incident and accident reporting, consent, the Mental Capacity Act and Gillick competency were now all available and accessible to staff.

The practice now had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance, such as the Infection prevention and control (IPC) audit, which had been completed 6 monthly.

Improvements had been made to the processes in place to identify and manage risks in relation to fire management, hazardous substances, infection prevention and control, and staff recruitment and training. For example, a new fire risk assessment had been carried out in line with legal requirements, by an external company on 23 September 2024. Recommendations within the assessment included installing emergency lighting and fire route signs and had all been completed.

Fire safety checks were being completed consistently, and regular fire drills were being carried out and documented.

Emergency equipment and medicines were available and were now being checked in accordance with national guidance at the appropriate intervals.

The premises were clean, well maintained and free from clutter. We saw evidence of effective cleaning schedules and that repairs had been carried out to the chair and worksurface in surgery 2. Hazardous substances were clearly labelled and stored safely.

Risk assessments to minimise the risk that could be caused from substances that are hazardous to health, had been reviewed and updated to include all substances and data sheets were available for all products.

The practice had completed a Data Protection Impact Assessment (DPIA) to assess how privacy may be impacted by the installation of closed-circuit television (CCTV).

The practice had also made further improvements:

At the inspection on 6 May 2025 we saw the sharps injury poster now included occupational health contact details. Sepsis awareness posters were also displayed around the practice.

We saw evidence that the practice completed infection prevention and control (IPC) audits in line with current guidance, with the most recent one completed in April 2025.

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.