The Leicester Street Practice Also known as The Gallery Dental Practice

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 identified and managed risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working. A fire safety risk assessment had been completed and there were some recommendations for action which remained outstanding; we were assured that work would be scheduled to address these issues and saw email correspondence regarding this.

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

Staff could access emergency equipment and medicines that were checked inline with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Staff also participated in medical emergency scenario training.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

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.

There was scope for improvement in the management of fire safety. The provider should assure themselves that checks made on emergency lighting were being completed for the required duration, in line with national guidance. Fire exits were clear and well signposted.

We saw that there were some issues for action identified in the electrical installation condition report (EICR) completed in 2023. We were told these issues had been addressed. There was no documentary evidence or further EICR report to confirm this.

The practice had systems for appropriate and safe management of medicines.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, evidence of immunity to hepatitis B was not available for all relevant staff on each occasion. Risk assessments were in place for those staff whose immunity levels were not confirmed. Following this inspection, we were sent an email demonstrating that blood tests had been booked for staff as required to provide evidence of their immunity levels.

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. 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 effective 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 annual appraisals, practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice. Staff said, “the practice is supportive, with a good team environment,” and “we have a fabulous team and all of us truly care about each other and our patients.”

The practice had infection control procedures that reflected published guidance. However, we noted that clinical areas did not have properly sealed flooring to comply with recognised guidance. The extractor fan in the decontamination room was not working; the fan controls were not easily accessible to staff. The decontamination room required decluttering. Following this inspection, we received evidence to demonstrate that the decontamination room had been decluttered and that a quote had been obtained for supply and fit of appropriate floor seals in clinical areas.

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 had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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 in line with current guidance.

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