Firswood 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.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.



Systems and processes were embedded, and staff worked together in such a way that where the assessment identified areas requiring improvement, these were acted on immediately.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

The practice had not completed a Data Protection Impact Assessment (DPIA) and the Closed-Circuit Television (CCTV) policy did not reflect our findings on the day. The provider completed the DPIA and updated the CCTV policy on 21 March 2025.

There were effective processes for identifying and managing risks, investigating incidents and accidents, and for receiving and acting on safety alerts.



The practice had systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits according to recognised guidance.  The sample size of the radiography audit needed to be increased to reflect current guidance. 

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We noted innovative approaches to providing person centred care.

Staff had clear responsibilities, and systems of accountability to support good governance. Staff held morning huddles to enable smooth-running of the day’s appointments.

Staff feedback was obtained through meetings, surveys, and 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.

Feedback from patients, the public and external partners was collected to which the practice responded.

The practice had taken steps to improve environmental sustainability. For example, the practice recycled all paper and cardboard, used paper cups in the clinical area’s and they turned off electronics off when not in use. The practice was working towards being paper free and used an online compliance system.

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.