White Hart Lane Clinic Limited

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 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.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice however, this was not always reflected in our findings.

The practice had processes to identify and manage some risks. We identified concerns with the assessment of risks and management of fire, electrical safety, and the control of substances hazardous to health (COSHH).

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support. Medical emergency equipment and medicines were checked, however, this was not at a frequency in line with national guidance and was not effective. On the day of the inspection not all emergency equipment and medicines recommended by the UK Resuscitation Council guidance were available. This included airways, masks to deliver oxygen, portable suction, a spacer device and the medicine to manage seizures, which was not available in the recommended formulation. All missing equipment and medicines were ordered immediately after the inspection.

The premises were visibly clean and free from clutter. Hazardous substances were clearly labelled and stored safely. The provider had completed Control of Substances Hazardous to Health (COSHH) risk assessments for dental and most cleaning products. Improvement was required to ensure that staff had access to safety data sheets for these products

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. On the day of the inspection, we saw that the servicing of the compressor was overdue.

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

The practice could not demonstrate that a comprehensive fire safety risk assessment had been undertaken by a trained and competent individual. The smoke detection system had been recently installed and fire extinguishers were in service, however the practice was not completing in-house testing of the smoke alarms or emergency lighting systems and the emergency lighting was last serviced in 2023. No fire training or fire drills were carried out by staff. Following our inspection, an external fire safety risk assessment was arranged for 3 February 2026 and we were told that the emergency lighting service would be arranged when renovation works were completed.

We were not provided with a copy of an Electrical Installation Condition Report which should be carried out every 5 years. This was booked for 19 January 2026.

The gas boiler had not been serviced since 2021. This was arranged following inspection feedback.

The practice had systems for appropriate and safe dispensing of medicines. However, improvement was required to ensure that NHS prescription pads were stored securely and a log was in place to monitor and track their use. This was rectified immediately after the inspection.

Whilst these issues were present, our concerns relate to lack of governance and risk oversight, rather than immediate patient and staff safety.

The practice recruitment procedures did not fully reflect relevant legislation, to help them employ suitable staff. Improvement was required to ensure the provider checked all information in respect of persons employed or appointed for the purposes of a regulated activity as set out in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some staff records did not include evidence of satisfactory conduct in previous employment, photographic identification or evidence to show the effectiveness of vaccination for Hepatitis B. Following our inspection, we were told that blood tests would be arranged for staff where required.

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 although improvement was required to record this in staff files.

Arrangements to ensure staff training was up-to-date and reviewed at the required intervals required strengthening.

We noted some members of staff had not completed training in autism and learning disability awareness, fire safety, sepsis awareness or safeguarding for children and vulnerable adults to the appropriate level or frequency for their role. Immediately after the inspection we were sent evidence to show that staff had now completed this training.

Staff 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.

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 annual appraisals, one-to-one meetings, practice team meetings and ongoing informal discussions.

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

One staff member told us, “Fantastic team work, staff and management are very helpful and it is easy to talk about anything.”

Another told us, “A well-supported a nurturing environment. Goals are the same to have a good working environment and happy patients.”

The practice had infection control procedures that mostly reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

An external Legionella risk assessment had been completed the day before the inspection and the recommended measures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line current guidance had not yet been implemented. The practice was not recording the hot and cold water temperatures or flushing an infrequently used water outlet. We were told these checks would be implemented immediately.

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