Leighton House Dental Practice

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found this practice was providing safe 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 Learning culture is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

The judgement for Safeguarding is based on the latest evidence we assessed for the Safe key question.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff we spoke with told us that equipment and instruments were well maintained and readily available. The provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice, and the reporting of risks was encouraged.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Improvements could be made to the effectiveness of these checks as we were told that the adult and child oxygen masks with reservoir and tubing were past their use by date and on the day of the assessment not all sizes of airways or clear face masks were available. All missing items were obtained immediately after the assessment. The premises were clean and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing and validation of most dental equipment in line with manufacturer’s instructions. However, there were no records to show that the ultrasonic bath had been serviced. A replacement ultrasonic bath was obtained after the assessment. A fire safety risk assessment was carried out in line with the legal requirements and the management of fire safety was mostly effective. Fire exits were clear and well signposted, and fire-fighting equipment was serviced and well maintained. We saw that fire evacuation drills were carried out at the practice and that staff had completed fire awareness training. Improvements could be made by implementing 6 monthly servicing and recording the in-house testing of the fire detection equipment. Immediately after the assessment we received evidence that the smoke detection system had received servicing on 11 October 2024 and a monitoring log was now in place to record in-house smoke alarm weekly tests.

The practice had not ensured the facilities were maintained in accordance with regulations and not all equipment was serviced and maintained in line with manufacturers instruction. On the day of the assessment the practice could not provide a satisfactory electrical installation condition report. In addition, the servicing of the air conditioning unit and gas boiler were both overdue as the evidence we saw showed they were last serviced in 2022. Following the assessment, we received evidence that the aforementioned had been satisfactorily completed on 11 October 2024. We also saw evidence that they had arranged for the gas appliance to be serviced on15 October 2024. The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health for dental products but had not included general cleaning products. Completed risk assessments for cleaning products were sent to us following the assessment. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety, sepsis awareness and lone working.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. One staff member said, “the practice supports all the staff and shares information so we can all learn new things and improve. Staff discussed their training needs during annual appraisals, 1 to 1 meetings, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. A staff member told us, “there is lots of support, mentoring, discussing a case and peer view and suggestions for courses to attend.” Staff we spoke with demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children. Staff told us they had received a structured induction programme, which included safeguarding.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had a structured induction, and clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Staff demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. Staff had appropriate training, and the practice completed infection prevention and control (IPC) audits in line with current guidance. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. Treatment of the water system and water quality checks were undertaken. However, improvement could be made by including a schematic diagram with the risk assessment to identify dead-legs within the system and by implementing periodic water temperature checks. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. However, improvement could be made so that the clinical waste container was better secured to a fixed structure.

The judgement for Medicines optimisation is based on the latest evidence we assessed for the Safe key question.