Northwick Park Dental Practice

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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 some systems in place to manage risks effectively, and staff were able to describe the relevant processes, including those related to sepsis awareness and lone working. However, improvements should be made to ensure that a safer sharps system was available in all treatment rooms and used consistently by all clinicians.

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 the practice manager told us that staff also participated in medical emergency scenario training. While some staff had completed emergency resuscitation and basic life support training, evidence of annual training in this core topic was not available for all staff members. Following the inspection, the provider was invited to submit additional evidence or documentation for consideration, however, no further training certificates were received.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of the autoclaves in line with manufacturer’s instructions. The most recent servicing record for the compressor was dated 21 January 2022. The practice manager told us that the compressor had been services recently and the updated servicing record was pending. Following the inspection the provider submitted the compressor servicing certificate, however, this did not include the pressure vessel inspection certificate. At the time of the inspection, the practice used a loan ultrasonic cleaner while their own unit was undergoing servicing, and no servicing record was available for review.

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

The practice had some systems in place to reduce the risk of fire. Annual servicing of the fire extinguishers had been arranged by the hospital and annual fire evacuation drills were being carried out by the practice.

We were provided with the practice fire risk assessment dated 1 May 2025. We were not assured that this was carried out by a person who had the qualifications, skills, competence and experience to do so. In addition, the assessment did not adequately consider key risk factors or accurately reflect the environment within the practice. For example, the document stated that gas appliances, external escape stairs and the sprinkler system were formally inspected by a competent third party, that appropriate emergency lighting was available and maintained by a third party, and that bells, whistles and horns used to raise alarm were checked weekly by the practice. During the inspection, we found no evidence of gas appliances, emergency lighting, a sprinkler system in the practice, or alarm mechanisms such as bells or whistles being in place. The document also stated that compressors were maintained and inspected according to manufacturer`s instructions and fire doors were indicated with appropriate signage. None of these statements were substantiated by our findings. This indicated that the fire risk assessment was not specific to the premises and did not provide an accurate or reliable evaluation of fire safety risks. Following the inspection the provider submitted an updated fire risk assessment dated 16 March 2026. We noted that this still included statements that did not accurately reflect the arrangements within the practice.

The provider told us that the hospital arranged annual fire risk assessment by a competent person, and the servicing of the fire alarm system. They also stated that the hospital had arrangements in place for the periodic in-house testing of the fire safety equipment. However, these documents were not available for review on the day of inspection, and no further documentation was submitted in response to our inspection feedback. Overall, we were not assured that that the provider established effective co-operation and co-ordination between duty holders in relation to fire safety matters.

Following the inspection the provider told us that they had arranged for an external fire risk assessment to be carried out. We were not provided further details as to when this would be undertaken.

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 to help them employ suitable staff. This reflected the relevant legislation. However, we found the policy was not always followed. Satisfactory evidence of conduct in previous employment concerned with the provision of health and social care, or work with children or vulnerable adults, was not available for all members of staff. In addition, a full employment history, together with a satisfactory explanation of any gaps in employment and proof of identity, including a recent photograph, was not available for all members of staff. Following the inspection and in response to our feedback, we invited the provider to submit further documents or information they wished us to consider as part of the inspection. We did not receive any recruitment documentation to demonstrate that the required records were available or that effective recruitment procedures were in place to ensure appropriate documentation was obtained and retained at the point of employment was maintained for persons employed.

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.

Evidence of role-specific training or continuous professional development was not available for all members of staff. Missing training certificates included but were not limited to: evidence of training in safeguarding vulnerable adults and children, medical emergencies, infection prevention and control, fire safety, radiography and interacting with people with a learning disability or autism. Overall, we were not assured that there were effective systems in place to monitor training to ensure that all core and role-specific training had been completed or to enable timely action where training requirements had not been met.

There were no systems in place to ensure staff received regular appraisal of their performance in their role to identify any training, learning and development needs.

Staff felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “This isa great place to work. The practice is well-organized, which makes daily tasks smooth and efficient. The team is friendly and collaborative, creating a positive and motivating environment. Leaders are helpful and supportive, always willing to guide and assist when needed. Overall, it’s a welcoming workplace where everyone feels valued and encouraged.”

The practice had infection control procedures that reflected published guidance.

Staff 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 protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

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

Improvements were required to the procedures in place to reduce the risk of Legionella, or other bacteria, developing in water systems. A Legionella risk assessment dated 25 November 2025 was made available for review. This included a number of high- and medium-risk recommendations. These included, but were not limited to formally recording the statutory duty holder and responsible person; implementing a system for regular monitoring of the control measures; ensuring those appointed to carry out the Legionella control measures are suitably informed, instructed and trained; producing an up-to-date schematic diagram of the layout of the water system, developing a Legionella scheme of control; investigating the causes of poor water system performance and carrying out monthly hot and cold water temperature checks. On the day of the inspection there was no evidence that recommendation made in the risk assessment had been actioned within the recommended timescales.

Following the inspection, the provider was invited to submit additional evidence or documentation for consideration, however, no further documentation was received in relation to the management of Legionella.

Records confirming Hepatitis B immunity were missing for some of the clinical staff members. On the day of the inspection, the provider was unable to demonstrate that the associated risks had been assessed or mitigated. This places staff at an increased risk of contracting infections, through needle-stick injuries or contact with contaminated sharps.

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