The Lytham Dental Clinic

On this page

• 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 19 March 2025.

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.

The principal dentist and staff told us of the systems in place to manage risks for patients, staff, equipment and the premises.

At the inspection on 4 November 2025, we found the practice had made the following improvements to comply with the regulation:

The improved system of policies and governance supported the practice to ensure good governance and leadership was in place.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, and we saw these were followed. Essential checks were carried out for new employees. There were systems to review these at appropriate intervals.

Staff demonstrated knowledge of safeguarding and who the practice lead was. The safeguarding policy and process included information to support the team to identify and quickly act on concerns.

The practice had implemented a system to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were processes for identifying and managing risks.

Improvements had been made to the systems to investigate and learn from incidents. Information was held securely, and the documentation of investigating and learning from significant events should had been improved to ensure these were discussed to avoid reoccurrence.

The log for documenting and tracking concerns and complaints had been improved to track the progress of these to ensure these were responded to and resolved in a timely way.

We saw recommendations in the installation report for the Dental Cone Beam Computed Tomography (CBCT) had been discussed with their Radiation Protection Advisor and acted on.

The dental compressors had been inspected and serviced. New electrical installation condition reports had been carried out in April and June 2025 which showed that concerns which were highlighted had been acted on promptly.

The management of fire safety was effective. A fire risk assessment had been completed. A new fire detection and emergency lighting system had been installed, which was tested by staff on a weekly basis. The rear fire exit had been cleared to enable escape to the assembly point. We noted one of the emergency lighting units did not appear to be working. The provider confirmed this would be investigated.

The practice had infection control procedures that reflected published guidance. However, these should be reviewed to ensure staff follow them consistently. Staff should carry out weekly testing of the ultrasonic cleaner and daily steam penetration testing of the vacuum autoclave. We observed not all staff used designated instrument transportation boxes, and the designated handwash sink should be kept clear of inappropriate items. The provider confirmed they would discuss this with staff to ensure they consistently follow the correct processes.

Evidence of satisfactory immunisation against Hepatitis B was obtained for all clinical staff, and arrangements were now in place to ensure staff could obtain timely advice and assessment in the event of a sharp’s injury.

There were procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A Legionella risk assessment had been carried out, and staff carried out water temperature monitoring on a monthly basis.

The practice had protocols to ensure effective cleaning and segregation and disposal of hazardous waste. A fully enclosed, rigid, lockable and weatherproof container had been installed for the safe storage of hazardous waste.

We highlighted the systems for checking medical emergency equipment and medicines could be improved by ensuring all items were included on the checklist accordance with national guidance, to highlight expiry dates for quick replacement, and arrange items to enable their quick retrieval. The provider assured us this would be implemented without delay.

Complaints were handled and documented effectively. Staff confirmed open communications and discussion were in place and a new system of meetings had been implemented.

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.