Cleggs Lane Dental Practice

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. Whilst there are issues to be addressed, the impact of our concerns relate to the governance and the oversight of the risks, rather than a patient safety risk.

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.

Staff had undertaken training in safeguarding vulnerable adults and children. This was completed the appropriate level and updated at appropriate intervals. Staff told us that there were sufficient staffing levels and demonstrated some knowledge of safeguarding. They were aware of how safeguarding information could be accessed. Staff knew how to identify adults and children at risk of significant harm. They told us they would report any concerns they had to the principal dentist or the practice manager. However, the provider did not have a documented safeguarding processes for staff to follow and staff did not know how to make a safeguarding referral with other agencies, such as the local authority if they had concerns. They were also unclear of their responsibilities for safeguarding vulnerable adults and children, particularly regarding the oversight of Was Not Brought within the practice. Was not brought is a code for when a child or an adult, who is reliant on another person to get an appointment, has missed their appointment. Missed appointments can be a sign of neglect and therefore providers should have appropriate safeguarding systems and processes to monitor and have oversight of missed appointments, particularly for children and vulnerable adults. We noted the safeguarding policy was generic and did not identify lead roles or specify local arrangements for safeguarding. The provider updated the safeguarding policy and safeguarding flowcharts on the same day as the assessment with details of the safeguarding leads and relevant local authorities.

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

The practice had processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff felt confident that risks were well managed at the practice. The premises were visibly clean, well maintained and free from clutter. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. The practice had systems for appropriate and safe handling of medicines. Most emergency equipment and most medicines were available and staff could access these in a timely way. However, the medical emergency kit was not checked in accordance with national guidance. The bodily fluids kit, blood spillage kit and eye wash kit were missing on the day of the assessment. The provider took immediate action and ordered all missing items on the day of the assessment. They also developed and implemented a new weekly checklist on the day. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff were also encouraged to participate in medical emergency scenario training. Hazardous substances were clearly labelled and stored safely. However, the practice did not have adequate governance systems to minimise the risk that could be caused from substances that are hazardous to health (COSHH). In particular, the practice did not have access to safety data sheets. We discussed this with the provider, and we were assured this would be addressed and rectified within the next 4 weeks. Fire exits were clear and well signposted. However, we highlighted that ongoing fire safety management was not always effective. The service for the fire alarm and the emergency lighting was overdue and monthly emergency lighting tests were not carried out or recorded. The provider booked the services, which were completed on 31 January 2025. During which, staff at the practice were shown how to test the emergency lighting and a checklist was created.

The practice had suitable procedures for the management of sharps. However, we noted information displayed within the sharps injury poster was not correct. The poster contained out-of-date information and was not available in the decontamination room. The provider took immediate action, and a new poster was created during the assessment and placed in all necessary areas. The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had an appropriate role specific structured induction. There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general well-being and aims for future professional development during annual appraisals, 1-to-1 meetings, during clinical supervision, practice team meetings and ongoing informal discussions. Staff stated they felt respected, supported and valued, and they were proud to work in the practice. The practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, oversight of staff training was not always effective. On the day of the assessment, we saw gaps in training completed for two members of staff for two required training modules. All outstanding training was completed on 30 January 2025.

The practice had infection control procedures that reflected published guidance. Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. However, the infection control policy was generic and did not identify lead roles or specify local arrangements within the practice. A new policy was created on the assessment day. We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance. We saw, and staff confirmed that single-use items were not reprocessed. The practice completed infection prevention and control audits in line with current guidance. The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. The equipment in use was maintained and serviced as per manufacturers’ instructions. Records were not available to demonstrate that the equipment used by staff for sterilising instruments was validated, maintained and used in line with the manufacturers’ guidance. The data logger for the autoclave (a machine used to disinfect reusable instruments) had not been accessed or downloaded since September 2024 and paper copies of autoclave cycles were not always kept. We discussed this with the provider and were assured this would be addressed and rectified. The practice had a risk assessment to reduce the risk of Legionella. However, records were not available to demonstrate that water testing and dental unit water line management were carried out. The provider acted immediately and carried out hot and cold water testing on the assessment day and temperatures were within the recommended limits.

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