East Finchley Smiles

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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 line with the relevant regulations and had taken into consideration appropriate guidance.

Although there are issues to be addressed, the impact of our concerns relates 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.

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.

The practice had systems in place to manage risks and staff we spoke with were able to describe the process. However, improvements were required to ensure the availability of a safer sharps system in all treatment rooms. Following inspection, the provider submitted evidence that a safer sharps system had been made available in all treatment rooms.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and this was broadly reflected in our findings.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff also participated in medical emergency scenario training.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Safety data sheets were available to staff and the practice carried out risk assessments for hazardous materials used within the practice as per Control of Substances Hazardous to Health Regulations 2002 (COSHH).

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

The practice managed fire safety well, and fire exits were clear and well signposted. Most recommendations made in the fire risk assessment dated 9 November 2024 had been actioned. These included replacing all non-complaint fire doors and the installation of carbon monoxide alarms. The provider told us that the outstanding recommendations relating to the installation of a fire blanket would be actioned without delay.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy that reflected relevant legislation, to help them employ suitable staff. Although recruitment documentation was available for most staff members, the policy was not consistently followed. On the day of the inspection, recruitment records for a recently appointed clinical member of staff did not include evidence of a Hepatitis B vaccination status or references relating to conduct in previous employment. A Disclosure and Barring Service (DBS) risk assessment was in place while the practice awaited the outcome of the DBS check, which had been applied for on 7 May 2026. Following inspection feedback, the provider submitted evidence that an appointment for the Hepatitis B blood test had been arranged and that references for the most recently employed staff member had been requested.

In addition, there was no evidence of recruitment checks for another staff member who provided cover one day a week, or for the visiting sedationist. Following the inspection, the provider informed us that they were in the process of obtaining the required recruitment documentation for these individuals.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

Newly appointed staff had received a structured induction. However, improvements were required to ensure, where appropriate, newly appointed staff were adequately supervised until they demonstrated acceptable levels of confidence to carry out their role independently.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Although training certificates were available for most staff members, evidence of training could not be provided for review for the most recently recruited clinical staff member, another staff member who provided cover one day a week, or for the visiting seditionist. In response to our inspection feedback, the provider submitted evidence confirming that the most recently appointed staff member had completed training in infection prevention and control, medical emergencies, safeguarding, and sepsis awareness.

There were processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice.

The practice infection prevention and control procedures did not always reflect published guidance. During observation of the decontamination process, staff did not consistently use appropriate personal protective equipment (PPE) and did not perform hand hygiene prior to commencing the procedure. A thermometer was not used to ensure that the water temperature for manual cleaning remained below 45°C, and instruments were not always fully immersed during scrubbing. We also observed practices during the decontamination process that increased the risk of cross-contamination In addition, staff demonstrated - limited knowledge and understanding of the autoclave validation process.

Sterilised instruments were stored uncovered on top of the autoclave, leaving them exposed to potential aerosol contamination. Overall, staff demonstrated limited knowledge and understanding of current national guidance relating to infection prevention and control procedures. In response to our inspection feedback, the provider submitted evidence to confirm that the staff member demonstrating the decontamination process had completed both infection prevention and infection prevention control lead training. Additionally, a clean transportation box had been introduced for the storage of sterilised instruments awaiting pouching, to reduce the risk of aerosol contamination.

While most staff had received training in infection prevention and control procedures, this training was not always effective in ensuring appropriate practices were consistently followed. Robust systems should be implemented to ensure all newly appointed staff receive comprehensive induction and training in practice-specific infection prevention and control procedures.

We saw, and staff confirmed that single-use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance. The auditing process required improvement to ensure it effectively identified areas where infection prevention and control procedures were not in line with current guidance.

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