Mr G Lai & Associates - Shepherds Bush

On this page

• 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. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. We were shown an email from an engineer advising that the compressor did not require external written scheme of examination due to its size. We discussed with the provider that advice should be sought about any in-house systems or processes they might need to implement to ensure the pressure vessel system is properly maintained. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained. However, improvements could be made to the overall management of risks associated with fire. A fire risk assessment dated April 2022 was made available for review. We were not assured that all recommendations made in the fire risk assessment had been acted upon. We were not assured that all recommendations made in the fire risk assessment had been acted upon. In response to our inspection feedback the provider told us that they would contact an independent engineer to evaluate the fire detection system in place and they were waiting for the builders to complete the installation of the fire resisting doors.

The practice ensured most equipment was safe to use and maintained and serviced according to manufacturers’ instructions. The practice ensured the facilities were maintained in accordance with regulations. We noted that servicing of the air conditioning system was overdue. In response to our inspection feedback, we were provided evidence that the servicing had been booked for 11 October 2024. The practice had some arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. We noted that recommendations made in the 3-yearly performance review dated June 2023 in relation to the national diagnostic reference levels had not been followed up. We brought this to the provider`s attention. They took immediate action and adjusted the settings accordingly. In addition, we were shown evidence that an external engineer had been contacted to rectify the issues with the intraoral X-ray switch unit. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. 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. Improvements could be made to ensure that the sharps and lone working risk assessments accurately reflected the arrangements within the practice. In response to our inspection feedback the provider told us that the relevant risk assessments had been updated. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out.

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. 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. 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.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These broadly reflected the relevant legislation. Improvements could be made to ensure that evidence of conduct in previous employment was obtained at the point of employment and the practice kept records of the induction staff received. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. 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. We noted that the dental chair had a tear and there were gaps along the skirting boards. We brought this to the provider`s attention and highlighted that these areas were not easily cleanable and could harbour bacteria. In response to our feedback, the provider told us that they had booked a contractor to reseal the skirting boards and to re-upholster the dental chair. Staff followed infection control principles, including the use of personal protective equipment (PPE). 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. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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