Willerby Dental Care 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.

The practice identified and managed risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working. We did highlight that improvements could be made to the risk assessments carried out in practice as they did not reflect practice protocols, the practice took this onboard.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice.

We noted that checks on emergency equipment and medicines were not done in accordance with national guidance, as a result, some equipment was missing. All missing equipment was ordered during the inspection day, and a new weekly medical emergency kit checklist was created during the inspection.

The practice should implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK).

They 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. However, we noted on the day that not allControl of Substances Hazardous to Healthitems (also known as COSHH) had been risk assessed and the relevant safety data sheets were not available for staff to view within the practice. Once this was highlighted, the practice assured us that risk assessments and safety data sheets would be made available for all hazardous substances in practice.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

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

The practice mostly managed fire safety well, however we noted some documentation relating to oversight and checks of the fire extinguishers and emergency lighting were not always completed. We discussed this with the provider who assured us this would be addressed and improvements made. Fire exits were clear and well signposted.

The practice should take action to ensure fire risk assessments are undertaken by a competent person and take action to implement any recommendations highlighted in the risk assessment.

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 their use. However, some staff were not aware of the process. Once highlighted to the practice we were assured that this would be addressed.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, records for current and newly employed staff were not accurate or complete. For example, on the day of inspection, we checked 10 recruitment files. Hepatitis B titre levels were not obtained for 2 members of the clinical staff. Titre levels are required to indicate levels of antibodies following a vaccination to ensure the vaccine has been effective. The practice acted quickly and sent evidence over that this information had been requested after the inspection.

References had not been obtained for 4 members of staff in line with the practices recruitment policy.

The practice should ensure they consistently follow their recruitment policies and procedures.

This should also include procedures to ensure accurate, complete and detailed records are maintained for all 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 had the skills, knowledge and experience to carry out their roles. We noted that a member of staff delivering direct access had not completed the appropriate training. Once highlighted, the member of staff completed the appropriate training and evidence was sent to us.

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. We highlighted on the day that a Was Not Brought process and knowledge was limited in practice. The practice acknowledged this and assured us that this would be reviewed and implemented. Was Not Brought is a safeguarding framework used in health and social care to record when a child or vulnerable adult misses an appointment because their carer failed to bring them.

The staff training, including continuing professional development, was mostly up-to-date. However, there was not an effective system in place to ensure staff remained up to date with mandatory training and continuing professional development requirements. As a result, fire safety awareness and Learning disability and Autism awareness training had lapsed for some staff. The practice acted quickly and we were sent evidence that this had been completed after the inspection.

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

The practice had infection control procedures however they did not always reflect the most up to date guidance, once highlighted to the practice they acted to ensure processes and policies were updated in line with 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 did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. We noted on the day that dip slide tests, a method used to monitor the general health and bacterial activity of a water system, were not being completed and documented in line with recommended guidance. On the day of inspection, a Legionella risk assessment had not been carried out. The provider confirmed this was completed after our inspection on 22 June 2026. The provider should ensure they addressany recommendations highlighted in the risk assessment.

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 however the frequency was not in line with current guidance. Once highlighted to the practice we were assured that the frequency would be completed in line with recognised guidance going forward.

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