Howard Stean - Mortlake Road Kew

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 accordance with the relevant regulations and had taken into consideration appropriate guidance. Where we found concerns relating to safe and effective staffing and safe environments, these were addressed immediately following feedback from the inspection team.

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 had processes to identify and manage risks. Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in immediate life support training. The premises were visibly clean. Hazardous substances were stored safely. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Fire exits were clear and well signposted. While we saw evidence of weekly in-house testing of the fire alarm system, improvements were required to ensure that fire safety equipment, including the fire alarm and fire extinguishers, were serviced regularly. Following feedback, the service provided evidence that servicing of the fire alarm system and fire extinguishers had been completed on 8 November 2024. The provider had scheduled for an Electrical Installation Condition Report, Portable Appliance Testing, an external fire risk assessment and gas safety servicing to be completed on 20 November 2024. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out.

At the time of our inspection, the practice was using agency nurses to provide chair side support. The practice did not have a recruitment policy to help them employ suitable staff, including agency or locum staff. Following our inspection, the practice sought assurances from the recruitment agency to demonstrate that the agency nurses had been subjected to the required recruitment checks, including Disclosing and Barring Service checks, proof of identity and evidence of immunity to Hepatitis B. The principal dentist was registered with the General Dental Council and had appropriate professional indemnity cover. They had completed continuing professional development required for their registration with the General Dental Council and to keep them up to date with advances in dentistry. However, improvements were required to ensure that staff kept up to date with training in fire safety and sepsis and mandatory training in interacting with people with a learning disability or autistic people. All CQC-registered providers must ensure staff are trained on how to interact appropriately with people with a learning disability and those with autism. The legal requirement was introduced by the Health and Care Act 2022 and came into effect on 1 July 2022. Following feedback, the principal dentist enrolled with an online training website to help them complete this mandatory training. The practice administrator demonstrated some knowledge of safeguarding and was aware of how safeguarding information could be accessed. We saw the practice administrator had completed safeguarding training at a level appropriate to their role, following our inspection.

The practice had infection control procedures that reflected published guidance. This included procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had cleaning procedures and schedules to ensure effective cleaning. We observed that the decontamination of used dental instruments aligned with national guidance. The equipment in use was maintained and serviced as per manufacturers’ instructions. We saw that single use items were not reprocessed. Staff followed infection control principles, including the use of personal protective equipment. We were informed that clinical waste was segregated but were unable to view where the clinical waste was stored. The practice completed infection prevention and control audits. Improvements were required to ensure these were completed every 6 months, in line with current guidance.

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