Roundhay Road Dental

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.

The practice demonstrated an open culture in relation to people’s safety. Prior to announcing our inspection, the provider had carried out a review of systems and processes and identified some omissions. The manager had prioritised these appropriately according to risk and was in the process of introducing and embedding new procedures and checks to ensure their effectiveness. This was a work in progress. For example, premises, sharps, lone working risk assessments and electrical safety testing had been carried out. We highlighted the need to ensure that contracted cleaners had appropriate lone working arrangements in place and the manager assured us this would be addressed.

The manager had arranged for an external health and safety company to carry out a full premises health and safety risk assessment on 17 April 2026 to support them to assess and mitigate risk. They had already created an action plan of the risks they had identified and had acted on the areas of highest risk.

Staff received sepsis awareness training and had resources to support them to identify and act on any concerns.

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 completed training in emergency resuscitation and basic life support every year. We highlighted there should be some scenario discussion and familiarisation for new staff who had missed the training session. We saw evidence further face to face training was booked in May 2026.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Staff had obtained safety data sheets for these substances and were in the process of risk assessing the hazards of the storage and use of these.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. The manager had created a spreadsheet to keep track of this.

The practice had arrangements to ensure the safety of the X-ray equipment which was serviced and tested at appropriate intervals. Not all of the required radiation protection information was available. However, these were sent to us after the inspection. We noted a recommendation to assess a partition wall in the installation report for one X-ray machine that the provider should discuss with their radiation protection advisor (RPA) that had not been acted on at the time. This was discussed with the provider to review with their RPA. We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings.

A fire risk assessment had been carried out just before our visit. The report included recommendations and the manager understood the requirement to act on these within the specified timeframes. Fire exits were clear and well signposted. Regular checks of fire safety equipment and evacuation drills had been initiated since February 2026 and new fire extinguishers were installed on 14 April 2026.

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 reflected relevant legislation, to help them employ suitable staff. This included carrying out right to work checks. A Disclosure and Barring Service (DBS) check had not been carried out at the point of employment for 1 new staff member. We signposted the provider to guidance to support them to update their processes.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had professional indemnity cover. The practice should check that indemnity cover is appropriate to the number of sessions worked. Where this was found to be an issue, immediate action was taken to address this.

Clinical staff had appropriate vaccinations against Hepatitis B and evidence of their effectiveness had been obtained. We saw where this evidence was not yet available, staff were appropriately risk assessed.

Newly appointed staff had an appropriate role specific structured induction.

Staff had the skills, knowledge and experience to carry out their roles. 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 manager had reviewed staff training, including continuing professional development and identified gaps and areas for improvement. In particular, ensuring staff completed training on, and follow infection prevention and control procedures consistently.

There were systems to discuss staff learning needs, general wellbeing and aims for future professional development during annual appraisals, one-to-one meetings, during clinical supervision, practice team meetings and ongoing informal discussions.

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

The infection control procedures should be reviewed to ensure these are clear to staff and reflect published guidance. They were in the process of ensuring staff received appropriate training in infection prevention and control processes, which were being monitored as inconsistencies had been identified, and these were reflected in our findings.

Staff did not consistently use heavy duty gloves whilst decontaminating instruments, and the gloves were not replaced at appropriate intervals. Dental instruments were decontaminated after each use, however there were inconsistencies in the processes followed. For example, an enzymatic spray to break down contamination on instruments was not used consistently; and we saw inconsistencies in whether staff used a validated cleaning device or manually scrubbed instruments to decontaminate them before sterilisation. We discussed these issues with the practice manager to support them to take appropriate action to address these. We saw, and staff confirmed that single-use items were not reprocessed. Sterilised instruments were visibly clean, pouched and stored appropriately.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. Staff carried out and logged water quality and temperature testing, the flushing of lesser used taps, and maintained dental unit waterlines appropriately. We noted a recommendation in the risk assessment report the provider should review whether point of use water heaters required ongoing servicing, but this had not yet been actioned.

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, and staff carried out regular validation checks. The manager had taken the decision to cease use of a steriliser until the printer was repaired to provide evidence of complete sterilisation cycles.

The practice manager had completed an infection prevention and control audit in line with current guidance to support them to highlight the issues to be addressed.

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