Tolworth Rise 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 relates to the governance and 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 arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available.

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.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. However, the medical emergency kit was not checked as frequently as recommended by the Resuscitation Council (UK). Since the inspection, we have received a log that the practice has implemented to document their medical emergency kit checks.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The practice had some processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice. However, this was not always reflected in our findings. A risk assessment had not been considered or carried out for a trainee member of staff who was not yet fully vaccinated but handling and decontaminating used instruments.

The practice did not have adequate governance systems in place to minimise the risk that could be caused from substances that are hazardous to health (COSHH). In particular, the practice had not completed risk assessments for each substance.

The premises were visibly clean, and the majority was well maintained and free from clutter. However, there was a room that was used for storage that was cluttered and contained a number of potential risks that the provider had not identified, for example access to sharp instruments and chemicals. Hazardous substances were stored here and were easily accessible to the public. Patients walked unattended through this room to reach the toilet. We raised this with staff and since the inspection have received a risk assessment of the room with an action plan and timeframe to address the risks.

We did not see satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. The equipment had been recently serviced. However, we did not see evidence of routine servicing and there were no previous servicing certificates available. The boiler had been serviced on 1 May 2025 and immediately taken out of use due to a cracked hot water pipe. We have since seen evidence that this has been fixed.

The management of fire safety was ineffective. The provider was unable to demonstrate that the fire risk assessment had been completed by a competent person in line with relevant legislation. There was no documented evidence to show fire extinguishers, smoke alarms and emergency lighting was checked regularly. Emergency lighting was not serviced, and staff did not know whether it required servicing. Fire drills were not carried out.

Since the inspection we have received evidence to show the provider has implemented a checking system for their fire equipment.

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.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of 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 had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were effective 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 stated they felt respected, supported and valued, and they were proud to work in the practice

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.

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 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.

The equipment in use was not maintained or serviced as per manufacturers’ instructions. We raised this with staff and were assured that they will put procedures in place to ensure this is not overlooked in future.

The practice completed infection prevention and control audits in line with current guidance

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