Kilburn Corner 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.

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.

You can find more details of our concerns in the detailed findings below.

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 did not always have effective systems to identify and manage risks.

Staff could access emergency equipment and medicines that were checked in line with national guidance. Although on the day of the inspection the practice did not have oromucosal midazolam, a medication used to treat prolonged epileptic seizures, we were shown evidence that it had been ordered. 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.

The practice carried out risk assessments for hazardous materials used within the practice in accordance with the Control of Substances Hazardous to Health Regulations 2002 (COSHH) and staff had access to the safety data sheets.

We saw satisfactory records of servicing and validation of autoclaves in line with manufacturer’s instructions. The practice had 2 compressors, however, we were advised that only 1 was in use. We requested the Written Scheme of Examination (WSE) for the compressors, but they were not available for review. The air compressor report on file was dated 18 April 2019 and was therefore out of date. Without a WSE inspection by a competent person, there was no assurance that the equipment remained safe for continued use, or that risks associated with pressure, temperature, and mechanical failure had been adequately controlled.

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

The management of fire safety was not effective. We reviewed the practice’s arrangements for identifying and mitigating fire risks. A fire risk assessment completed by a competent person on 21 January 2026 identified several high and medium-risk recommendations that had not been addressed within the required timescales. These included deficiencies relating to fire-resisting doors and fire door fittings and labelling, fire compartmentation and escape routes, the positioning and annual inspection of fire extinguishers, and the completion of annual fire drills. We noted that the actions relating to fire door labelling, annual inspection of fire extinguishers and annual fire drills had remained outstanding since 2019 and had also been identified in the previous fire risk assessment.

We requested the Electrical Installations Condition Report (EICR) for the premises, however, this was not available for review. Without an EICR, there is no assurance that the fixed electrical installation has been inspected, tested, and confirmed as safe.

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 recruitment policy and procedures did not reflect relevant legislation. The required recruitment documentation was not available for some members of staff. Missing documents included proof of identity including a recent photograph, enhanced criminal record certificate, satisfactory evidence of conduct in previous employment, full employment history and Hepatitis B vaccination records. In addition, satisfactory evidence of conduct in previous employment and full employment history were not available for review for a further 4 staff members. As a result, the provider could not demonstrate that robust recruitment procedures were consistently followed to ensure staff were suitable for their roles.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

There were no systems in place to ensure staff received induction when they started their new role. Induction records were not available for any members of staff.

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.

The practice ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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. We requested, but were not provided with, recent appraisal or performance review records for any members of staff.

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

The practice had infection control procedures that reflected published 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.

We reviewed the practice’s arrangements for identifying and mitigating the risks of Legionella and other bacteria developing within the water systems. A Legionella risk assessment completed by a competent person on 20 June 2024 identified several high and medium-risk recommendations that had not been addressed within the specified timescales. These included requirements for annual inspection and cleaning of the hot water storage vessel, maintaining appropriate hot water temperatures and insulating pipework to individual outlets, reviewing and removing infrequently used water outlets where appropriate, and implementing and recording a regular flushing regime for infrequently used outlets. There was no evidence that infrequently used showers had been removed from service, and the most recent documented flushing of infrequently used outlets was dated February 2026.

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.

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