Westlands Dental Studio

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 not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure they have been put right by the provider.

During our assessment of this key question, we found the registered person had systems or processes that operated ineffectively in that they failed to enable them to assess, monitor and improve the quality and safety of the services being provided. We also found concerns around the ineffectiveness of the 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.

This resulted in a breach of Regulation 17 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.

The assessment highlighted areas where improvements were needed, such as risk management and adherence to published guidance.

Improvements should be made to the oversight of the leadership team to ensure that the practice’s clinical governance systems and processes were followed and risks managed appropriately.

The practice did not have adequate systems in place for identifying, assessing and mitigating risks in areas such as the completion of risk assessments, training and recruitment, hazardous substances and legionella.

The practice’s systems and processes for learning, quality assurance and continuous improvement, needed improvements to ensure audits undertaken at the required intervals. The audits had not identified the areas of improvement highlighted within our assessment for example in relation to the prescribing of antibiotics.

Systems were in place to ensure concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

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



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. Staff had access to electronic devices to assist patients when reviewing and signing documents.

Staff feedback was obtained through meetings, surveys, and informal discussions. They were encouraged to offer suggestions for improvements to the service. Some staff stated leaders were approachable and listened to their comments, but felt at times the group structure meant it took time to achieve meaningful change.

The practice had taken steps to improve environmental sustainability. For example, recycling oral health products, general recycling where possible and automatic lights in toilets.

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.