Sutton Smile Spa

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.

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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff we spoke with told us that equipment and instruments were well maintained and readily available. The provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice and the reporting of risks was encouraged.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. The premises were 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. Fire exits were clear and well signposted on the ground floor of the practice. There was no fire exit directional signs on the first floor. We were assured that new signs would be purchased and put in place immediately. Fire safety equipment was overdue for service we were shown evidence to demonstrate that a service had been booked for 17 January 2025. Staff were not checking the fire alarm at the required frequency and there was no documentary evidence to demonstrate that fire extinguishers, fire doors or exit routes were being checked by staff. The provider assured us that new checks would be put in place immediately.

The practice ensured equipment was safe to use, maintained and serviced according to manufacturers’ instructions. There was scope for improvement to ensure that the facilities were maintained in accordance with regulations. A new gas boiler and electrical fuse board were fitted during the practice refurbishment in 2023. The gas boiler had not been serviced at the frequency suggested in the commissioning document and there was no electrical installation condition report (EICR). We were shown an electrical installation report for the new fuse board. Following this assessment we were sent a copy of an EICR completed on 15 January 2025 and evidence that the gas boiler service was scheduled for 26 February 2025. There was no evidence that a fire safety risk assessment had been carried out in line with the legal requirements. We were told that a risk assessment had been completed previously but documentation was not available. Following this assessment, we were sent evidence to demonstrate that an external company had completed a fire risk assessment on 14 January 2025 and were assured that any issues for action would be addressed. The practice had some arrangements to ensure the safety of X-ray equipment and the required radiation protection information was available. Commissioning information for the hand held X-ray unit, which we were told was currently not in use, was not available. Risk assessments to minimise the risk that could be caused from substances that are hazardous to health were not available. Safety data sheets were available. During this assessment a member of staff was given the task of developing risk assessments for products in use, using the practice’s compliance system. The practice had systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety, sepsis awareness and lone working. Antimicrobial prescribing audits were carried out and systems were in place for appropriate and safe handling of medicines.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during annual appraisals, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. Staff we spoke with demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. However there was scope for improvement regarding staff knowledge of ‘was not brought’ policies and procedures (when a child or vulnerable adult is not brought to an appointment). The practice manager confirmed this would be discussed with staff during the next practice meeting.

The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. Although all staff had disclosure and barring service checks, the check for one staff member was not at the required level. We were assured that this would be addressed. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had a structured induction. Clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice’s arrangements to ensure staff training was up to date and reviewed at the required intervals required strengthening. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

The practice appeared clean, external cleaners were employed to clean the general areas of the practice. There was a cleaning log which referred to a cleaning schedule. We were not provided with a copy of the cleaning schedule during this assessment. The practice manager confirmed that a cleaning schedule would be developed and kept with the cleaning records for easy access. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Staff demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. Staff had appropriate training, and the practice completed infection prevention and control (IPC) audits in line with current guidance. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. The practice was refurbished in 2023, a legionella risk assessment had not been completed since that date but we were shown evidence to demonstrate that this was scheduled to take place on 20 January 2025. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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