Chana Dental Practice - Leeds

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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 25 July 2024.

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 7 May 2025 we found the practice had made the following improvements to comply with the regulation:

Hazardous substances had been risk assessed, and they were clearly labelled and stored safely.

Some improvement had been made with the management of fire safety. However, the practice should take action to implement recommendations in the practice’s fire safety risk assessment and ensure ongoing fire safety management is effective.

Fire exits were clear and well signposted.

The practice had a fire risk assessment completed by a competent person in July 2024.

We reviewed the fire risk assessment and saw there were 35 actions identified, 18 of which were priority 1 and 17 were priority 2. As at 7 May 2025, there were 5 outstanding actions left. However, the provider could not demonstrate that the risk assessment actions were being recorded accurately. For example, the action to ensure all staff carried out fire safety training had been recorded as completed on the risk assessment, but we only saw evidence that 1 of the 3 staff members had completed fire safety training. We also noted actions had not been ticked as completed but had seen they had been addressed.

Following the inspection we were sent evidence that fire safety training had been completed by all members of staff.

The practice had installed a new fire alarm on 27 September 2024. However, we noted the fire alarm had not been tested weekly since it was installed. We discussed this with the provider and a new weekly checklist was created following the assessment.

Fire extinguishers had been serviced on 11 March 2025 but the practice was not carrying out or recording the monthly visual checks. We discussed this with the provider and a new monthly checklist was created following the assessment.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. At our inspection on 25 July 2024, we saw no evidence of immunity to Hepatitis B for 2 clinical members of staff. At our inspection on 7 May 2025 there was still no evidence of immunity to Hepatitis B for those staff members. We discussed this with the provider and Hepatitis B risk assessments were completed and Hepatitis B immunity tests were ordered on 7 May 2025.

The practice had improved their procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, the provider had not identified that an unused washing machine in the basement, which had not been used for at least 2-years, was classified as a lesser used outlet that required flushing. We discussed this with the provider who assured us this would be done moving forward.

At the inspection on 25 July 2024, we noted patient care records were not always in line with national guidance. We looked at 10 patient care records on 7 May 2025 and saw record keeping had improved. The information recorded in these patient care records was mostly in line with recognised guidance. We noted that antibiotic justification was not always recorded.

Staff obtained patients’ consent for treatment in line with legislation and guidance and understood their responsibilities under the Mental Capacity Act 2005 however this was not always recorded within the patient care records. Staff described how they involved patients’ relatives or carers when appropriate and made sure they had enough time to explain treatment options clearly. The patient care records we reviewed all had the same 6 month recall time period (the interval between each appointment), we saw no evidence that these recall times had been personalised to meet the needs of each patient.

The practice had a governance system which included policies, protocols and procedures that were accessible to all members of staff and were reviewed on a regular basis.

Areas identified as requiring improvement at the inspection on 25 July 2024 had mostly been addressed. The follow-up inspection on 7 May 2025, highlighted that further improvements should be made to oversight systems and processes for fire safety, dental care records, and immunity of blood-borne viruses for clinical staff.

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.