Trafalgar Woolston Also known as Smile Dental Care Group - Southampton

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 7 May 2026 we found the practice had made the following improvements to comply with the regulation:

Improvements had been made to ensure the management of fire safety was now effective. A risk assessment had been completed in line with guidance and regulations. We saw that all fire safety measures were being carried out and documented consistently, including weekly fire alarm checks, and monthly emergency lighting checks. Fire extinguishers and fire detection systems had been serviced.

Actions arising from a Legionella risk assessment and Electrical Installation Condition Report (EICR) undertaken prior to the inspection on 22 May 2025 had been completed.

The practice had recently undergone a period of renovation with the addition of 2 new surgeries. The provider told us both Legionella and fire risk assessments would be repeated following completion of the building works and sent to us.

The premises were free from clutter and visibly clean, although there were still areas with visible signs of wear and tear, for example rust on dental chairs; which were brought to the attention of the provider.

Improvements had been made to the processes of decontamination of dental instruments which were in line with current guidelines. A new decontamination room had been constructed. The practice was required to update its infection prevention and control policy to reflect the changes and installation of new equipment.

Further improvements were still required to ensure that complete and detailed records were maintained for all staff; and that the practice was working in line with its recruitment policy. For example, we saw that new staff did not always have a suitable Disclosure and Barring Services (DBS) check, a full employment history with satisfactory explanation of gaps in employment; and health assessments were not routinely completed. Additionally, further actions are required to ensure an appropriate understanding of immunisation against hepatitis B to enable all staff to have the necessary evidence; and risk assessments in place as applicable.

At the inspection on 7 May 2026 we found the practice had made the following improvements to comply with the regulation:

We saw that the practice had made improvements in ensuring that staff training, including continuing professional development (CPD) was up to date and reviewed at the required intervals. Staff inductions were thorough with effective systems for the oversight of trainee staff. However, further improvements are required to the systems for monitoring and tracking training to ensure that lapses do not occur.

The practice had updated their systems for quality assurance and had carried out audits of disability access, antimicrobial prescribing and radiographs. We noted that whilst some templates had been updated, further improvements were underway to ensure audits were completed in line with guidance; and findings were clearly documented with learning points and evidence these had been shared and actioned.

We reviewed the practice’s processes for complaints. A complaints tracker had recently been implemented to enable the practice to identify themes and patterns in order to monitor and continually improve.

Whilst staff were aware of the importance of protecting patients’ personal information, action was required to ensure the ongoing appropriate storage of records and materials throughout the building.

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.