Cleggs Lane Dental Practice

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was providing well-led care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 29 January 2025.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

At the inspection on 14 May 2025, we found the practice had made the following improvements to comply with the regulation:

The safeguarding policy had been personalised to the practice, including details of the safeguarding leads at the practice and identified specific local arrangements for safeguarding.

The practice had implemented a formal process to record and monitor the oversight of Was Not Brought within the practice. Was Not Brought applies to vulnerable adults and children and young people who require the presence or rely on the support of a parent or carer to attend appointments, who did not attend a planned appointment.

Staff knew how to identify adults and children at risk of significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral or who to inform if they had concerns. This included referrals with other agencies, such as the local authority.

Emergency equipment and medicines were checked in accordance with national guidance. Staff had created a new medical emergency kit checklist during the inspection on 29 January 2025. We saw this process was embedded on our inspection on 14 May 2025. Staff could access the kit in a timely way.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. Systems and processes to minimise the risk that could be caused from substances that are hazardous to health had been improved. Staff now had access to safety data sheets for all hazardous substances.

The management of fire safety was effective, and fire exits were clear and well signposted. The practice had been shown how to test the emergency lighting. We saw this had been tested monthly, in line with guidance, since the emergency lighting was serviced on 31 January 2025. We saw evidence that the fire alarm had been serviced on 31 January 2025.

The practice had infection control procedures that reflected published guidance. The practice had updated their infection control policy to reflect procedures at the practice and included details of the infection control lead.

The equipment in use was maintained and serviced as per manufacturers’ instructions. The data logger for the autoclave (a machine used to disinfect reusable instruments) was now downloaded weekly.

Hot and cold water temperature checks were within the recommended ranges following a risk assessment at the practice. We saw evidence of monthly temperature checks from January 2025 up until May 2025.

At the inspection on 14 May 2025, we found the practice had made the following improvements to comply with the regulation:

Systems and processes were embedded, and the follow-up inspection did not highlight any issues or omissions.

The practice’s systems and processes for managing and having oversight of risks and issues were clear, effective and embedded. Staff could describe the systems to manage risks for patients, staff, equipment and the premises. This included the implementation of tracking system for NHS prescription pads.

Policies relating to safeguarding and infection prevention and control had been updated to reflect protocols at the practice.

Systems and processes to provide oversight of completed staff training had been improved. We saw evidence that all staff training was up-to-date.

Displayed information in sharps injury posters had been updated and placed in all relevant areas.

Staff had access to safety data sheets relating to Control of Substances Hazardous to Health.

Governance of ongoing monitoring of fire safety had been improved, and relevant servicing had been completed on the fire alarm and emergency lighting.

Records to demonstrate ongoing monitoring of water and dental unit water line management were now available.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.