Swakeleys 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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breaches we found at our assessment on 13 September 2024.

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 and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises.

At the assessment on 14 March 2025, we found the practice had made the following improvements to comply with the regulations:

The provider described the processes they had in place to identify and manage risks. Since the last on-site assessment, the practice has signed up to a compliance portal. This has improved ongoing oversight and scrutiny and the monitoring of risk.

Emergency equipment and medicines were now available and checked in accordance with national guidance. Staff could access these in a timely way. The practice checked medical emergency drugs and equipment weekly as set out in the relevant guidance published by the Resuscitation Council (UK).

The electrical installation condition report completed in January 2025 stated that the overall assessment of the installations in terms of suitability for continued use was unsatisfactory. The report listed a significant number of recommendations, including some that required immediate action due to the risk of injury. At the time of our follow up on-site assessment, the recommended remedial actions had not been completed. In response to our assessment feedback the provider told us that an electrician was arranged and the first phase of work was due to commence in the middle of April 2025 and the remaining work to be completed by mid-May 2025.

A fire risk assessment completed by a competent person on 17 October 2024 was made available for review. The practice had an emergency lighting system fitted and additional smoke detectors had been installed in line with the recommendations of the fire risk assessment. The practice had systems in place for the periodic in-house testing of the fire safety equipment. Fire evacuation drills were being carried out and staff had completed fire awareness training. Overall, improvements had been made to ensure the management of fire safety was effective.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. Further improvements could be made to ensure the Health and Safety risk assessment included control measures to reduce the risk associated with patients seen in the upstairs surgery having to walk down the stairs to have an X-Ray taken during a procedure.

A sharps risk assessment had been completed, and it now reflected arrangements within the practice. Two clinical staff members had recently completed their third dose of Hepatitis B vaccinations, and they were scheduled to have blood tests to check their responses to the vaccine.

At the assessment on 14 March 2025, we found the practice had made the following improvements to comply with the regulations:

The provider told us that staff had access to the compliance portal they had recently subscribed to, which included Continuous Professional Development (CPD) courses and other compliance activities.

Improvements had been made to ensure there was adequate supervision and support by the principal dentists for the nursing and wider team. Staff were now supported in their training and carrying out their duties.

The provider told us that moving forward they would ensure that they follow their recruitment policy which included induction for new staff and requesting the appropriate documentation at the point of employment.

We saw that the required recruitment documentation had been requested for a new staff member the practice had employed since the last on-site assessment. This included proof of identity including photograph ID, enhanced Disclosure and Barring Service (DBS) certificate, evidence of conduct in previous employment and full employment history.

Improvements had been made to ensure staff training was up-to-date and reviewed at regular intervals. Staff had completed training in basic life support, autism and learning disability awareness, fire safety, legionella, sepsis awareness and infection prevention and control.

At the assessment on 14 March 2025, we found the practice had made the following improvements to comply with the regulations:

We observed the decontamination of used dental instruments, and this now aligned with national guidance. Staff used appropriate detergent to disinfect instruments during scrubbing and instruments were fully immersed during the cleaning process. The temperature of water was monitored to ensure it was 45C or lower. Staff performed handwashing when undertaking decontamination.

Improvements have been made to ensure there was a separation of instruments reprocessing from other activities by physical or temporal means. The sliding door separating the kitchen from the decontamination room was kept closed during the decontamination process.

Staff had appropriate knowledge of infection prevention and control and all clinical staff members had completed infection prevention and control training. The practice completed infection prevention and control audits bi-annually and this suitably identified actions to drive continuous improvements.

The practice had identified that the hot water outlets did not always reach 50C as per the Legionella risk assessment and they had plans in place to rectify this issue by making adjustments to the boiler.

At the assessment on 14 March 2025, we found the practice had made the following improvements to comply with the regulations:

We saw that prescription only medication and prescription pads were stored securely and there was an effective stock control system in place.

Antimicrobial prescribing audits were being carried out. Improvements could be made to ensure these are aligned to the current guidance.