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

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, and this was mostly reflected in our findings.

The practice identified and managed most risks effectively and staff described the processes.

On the day of the inspection, we noted that the practice had not fully identified and mitigated all risks associated with sharps and lone working. The practice had not considered all sharps used at the practice in their risk assessment and had not identified that protective devices should be available to safely manage used needles. Immediately following the inspection, we were provided with an updated comprehensive sharps risk assessment and evidence that they had obtained sharps protective devices. In addition, they had not completed a risk assessment for the dental hygienists who worked without chairside support. Following our feedback a risk assessment was completed.

Staff could access emergency equipment and medicines and checked their emergency medicines in line with national guidance. Improvement was needed to include a weekly check of the emergency equipment, as on the day of the inspection, we saw that a number of airways and masks were past their use by date. Immediately following the inspection all out of date medical equipment and oral glucose, a medicine to manage low blood sugar, which was missing were ordered.

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

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. On the day of the inspection, we saw that the provider had completed Control of Substances Hazardous to Health (COSHH) risk assessments and obtained safety data sheets for dental materials and most of the cleaning solutions used at the practice. Following our feedback they obtained these for the remaining general cleaning products.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. We saw that the air conditioning units had not been serviced since they were installed in 2021. Following our feedback a service was scheduled for 21 May 2026.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT) X-ray equipment.

The practice had completed an in house fire risk assessment annually although we were not assured that this had been undertaken by a trained and competent individual to identify all risks associated with fire. We were provided with evidence to demonstrate that the practice had scheduled an external company to carry out an additional risk assessment on 17 May 2026. We saw that the smoke detection system and fire extinguishers were in service, fire exits were clear and well signposted and fire evacuation drills were undertaken. However, the practice was not completing in-house testing of the smoke alarms or emergency lighting systems and the emergency lighting had not been serviced. Following our feedback the practice arranged for the servicing of the emergency lighting to be undertaken and implemented in house checks of the smoke alarms.

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 and procedures that mostly reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. Improvements could be made to ensure evidence of conduct in previous employment concerned with services relating to health and social care, or children or vulnerable adults were obtained prior to employment.

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 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.

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 one-to-one meetings, practice team meetings and ongoing informal discussions. The provider could make improvements by ensuring annual appraisals were completed with staff.

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

One staff member told us about the additional roles and responsibilities they had been given at 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.

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.

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 mostly maintained and serviced in line with manufacturers’ instructions. However, we saw that the ultrasonic bath had not been serviced. Following the inspection, the practice provided evidence that they had purchased a new ultrasonic bath.

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.