Ewood House Dental Surgery

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.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises.

At the assessment on 25 February 2025 we found the practice had made the following improvements to comply with the regulation.

Improvements had been made to ensure an accurate stock control system was maintained as part of the management of medicines.

The system to manage risks associated with Legionella had been improved to ensure where risks were identified, prompt action would be taken.

Risk assessments had been adjusted to reflect protocols at the practice.

The practice had reviewed the risk assessments as part of the management of hazardous substances as a team and remedial actions were now included.

Improvements had been made to the systems for managing recruitment. We looked at records for new members of staff and found all important checks had been carried out at the point of recruitment.

Training records were available for all staff members involved in the delivery of care under conscious sedation. In addition, we saw that systems had been updated to ensure these were consistently obtained.

We observed that staff adhered to published guidance in relation to infection prevention and control. In addition, changes had been made to the layout of the decontamination room to ensure it more accurately aligned to guidance, including The Health Technical Memorandum 01-05: Decontamination in primary care dental practices, (HTM 01-05).

The infection prevention and control audit had been repeated since our last assessment and accurately reflected our findings on the day. In addition the system had been improved to ensure it would be undertaken at the required intervals.

Lockable cabinets had been purchased to ensure patient care records were consistently stored securely.

The practice had also made further improvements:

A number of the recommendations made in the recent fire risk assessment had been actioned and a plan was in place to complete the remainder in the short-term. In addition, we saw the fire exits were kept clear.

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.