VitaSmile

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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 not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found concerns reacted to:

a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided and

a lack of systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

These concerns were in breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the detailed findings below.

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.

We found that there was ineffective leadership which impacted the practice`s ability to deliver safe and effective care. We were not assured that the registered manager understood their role and responsibilities in relation to the day-to-day management and oversight of the service. They did not demonstrate sufficient understanding of the legal requirements or relevant guidance needed to ensure the service operated safely and in accordance with regulations.

The registered manager did not demonstrate awareness of their role in ensuring that adequate and effective governance systems are established and maintained. This included processes to identify, assess, and manage risks relating to fire safety, Legionella, radiation safety, infection prevention and control, sharps safety, and equipment safety. For example, they were unaware of the significant findings of the practice’s Legionella risk assessment, some of which required urgent action. This lack of oversight and understanding of governance responsibilities increased the risk that hazards would not be effectively identified or managed.

The information and evidence presented during the inspection was not clear or well documented.

The General Health and Safety Risk Assessment dated 1 December 2025, did not suitably identify workplace hazards, evaluate associated risks, and implement appropriate control measures to protect employees, visitors, and contractors from harm. For example, it stated that staff are appropriately trained as competent, including appropriate safety measures (infection control); staff are fire awareness trained, including an appropriate number of trained fire wardens; radiation equipment is maintained according to the relevant regulations and Legionella control measures have been implemented. None of these statements were substantiated by our findings. In the absence of a comprehensive health and safety risk assessment, there was no systematic approach to identifying, controlling, and mitigating hazards in the workplace.

There were no systems in place to ensure recalls and rapid response reports relevant to the service issued by the Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and shared with staff.

The practice did not have an effective governance system, and we were not assured that policies and procedures were reviewed on a regular basis.

The infection prevention and control policy dated October 2022 was not tailored to the practice’s actual arrangements. It identified an individual, who did not work at the service, as the designated infection prevention and control lead and referenced a different unrelated service as responsible for providing appropriate personal protective equipment for staff. In addition, the policy did not contain practice-specific procedures for manual cleaning of instruments or for the management of dental unit waterlines, taking into account the complexity of the practice’s water system.

The Safeguarding Policy displayed at reception contained inaccurate information, referring to Westminster as the relevant local authority for external escalation, despite the service being located in Brent. Overall, we found that these policies were not suitable to guide staff in the carrying out their day-to-day duties and did not include systems and processes reflective of the service.

The practice did not have effective systems and processes for learning, quality assurance and continuous improvement. There was a lack of understanding of what data should be included in audits and how the review of processes could identify where quality and safety were compromised. The practice could not demonstrate that audits of infection prevention and control, record keeping, radiography or antimicrobial prescribing were carried out regularly to support continuous improvement. The only available infection prevention and control audit was dated 4 December 2025 and no record keeping, radiography, antimicrobial prescribing, or other audits were available for review. The absence of regular and comprehensive auditing limited the provider’s ability to identify non‑compliance, poor practice, or opportunities for improvement, which increased the risk that issues remained unaddressed.

Staff did not have clear responsibilities or systems of accountability to support good governance. The staff member identified in the Safeguarding Policy as the safeguarding lead, was unaware of this responsibility and stated that another staff member held this role. The principal dentist who was responsible for trainee nurse supervision lacked sufficient knowledge of infection prevention and control, the management of medical emergencies and safeguarding.

The provider told us that the service did not carry out formal or structured patient satisfaction surveys. Without a systematic process for gathering, reviewing and acting on patient feedback, issues such as unsafe practices, staff conduct concerns, or gaps in care may go unidentified and unresolved.

Staff feedback was obtained through informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate. However, improvements were required to strengthen formal governance arrangements. In particular, the practice did not consistently hold regular, structured meetings to review key areas such as policy updates, risk assessment findings, and lessons learned from incidents or feedback.

The provider told us that they had not received any complaints within the past 12 month, however there were systems in place to ensure concerns and complaints were responded to appropriately.

The practice had taken steps to improve environmental sustainability. They promoted recycling, reduced paper use where possible, and was mindful of energy consumption, such as turning off equipment when not in use.

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.