Holloway House Dental Surgery

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

The provider made sufficient improvements to put right the shortfalls and had responded to the regulatory breach we found at our inspection on 6 January 2026.

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.

At the inspection on 18 August 2026, we found the practice had made the following improvements to comply with the regulation:

Areas inside and outside the rear of the practice were clear and free of waste, clinical equipment and materials.
Control of substances hazardous to health (COSHH) risk assessments were available for COSHH identified products used in the practice.
COSHH safety data sheets were available for COSHH identified products used in the practice.

The practice was able to demonstrate that fire drills were carried out.
The practice had an external fire risk assessment carried out in June 2026. We will assess progress with the required action plan at our next visit.
Automatic emergency lighting was available.

The practice was able to demonstrate that the five yearly electrical installation condition report (EICR) had been carried out.
The practice was able to demonstrate that the air conditioning was serviced appropriately.

An in-date blood spillage kit was available.
The first aid kit was in-date and fit for use.
Dispersible aspirin was present in the medical emergency kit.
Glucagon was stored in the medical emergency kit. The expiry date was altered to reflect these storage arrangements (out of a fridge).

NHS prescriptions pads were monitored to prevent fraudulent misuse. Further improvements should be made to track and audit individual prescriptions.
Clinicians we spoke with demonstrated an understanding of consent protocols for people who had fluctuating mental capacity.

We found a number of shortfalls that remained outstanding from our previous inspection:
Hazardous substances were not always stored in line with the control of substances hazardous to health (COSHH) regulations. We saw a quantity of metal canisters filled with combustible fuel present in an unlocked and labelled cupboard.

The practice was unable to demonstrate that the fire alarm was tested appropriately.
We were shown a logbook and noted that the most recent alarm test recorded was 26 June 2026.
The practice was unable to demonstrate that the fire alarm was serviced appropriately as a service was due on 27 June 2026.
The practice was unable to demonstrate that the emergency lights were tested appropriately. We saw two entries in the fire safety test logbook, both were undated.
 

We also found a number of additional shortfalls:
Electrical wires were ‘daisy chained’ under a desk in the manager’s office. Daisy chaining overloads electrical capacity and can generate excessive heat.
An out-building, at the rear of the practice, was used to house the compressor. This area was neither secure nor displayed a COSHH warning sign.

We observed a student dental nurse grading a radiograph the dentist had taken. The provider was unaware that members of the nursing team can only do this independently if their training, competence assessment and the practice's written procedures authorise them to perform radiographic image-quality assessment.

X-ray machine local rules did not include all of the staff who took x-rays. Two clinicians had started to work at the practice since our last visit, and one clinician had left. The local rules had not been updated to reflect these changes.

A handheld x-ray machine was stored in a locked cabinet in the manager’s office. We noted the cabinet was not labelled appropriately.

The judgement for Safe and effective staffing is based on the latest evidence we assessed for the Safe key question.

At the inspection on 18 August 2026,we found the practice had made the following improvements to comply with the regulation:

Local anaesthetic ampules, seen in treatment room drawers, were stored appropriately to prevent the risk of cross contamination.
Surgery 1 and 3 endodontic instrument kits were stored appropriately.
Instrument pouches were sealed and dated with in line with national guidance.
Pouched instruments were seen being used in treatment rooms.

Flooring in the ground floor patient toilet, staff toilet and kitchen area had been replaced and was impervious.
An annual infection prevention and control statement was available.
Hot water was available in staff and patient toilet and staff kitchen.

A foot operated clinical waste bin was available next to the x-ray developing machine.

Hand cleaning facilities were available at the hand-wash sink in the decontamination room. Three wall mounted hand cleaning product containers were present but only two were labelled. The practice should label the third container as soon as practicably possible.

Staff manually cleaned instruments before placing them in a steriliser. The cleaning agent to water dilution ratio was measured.
A manual cleaning scrubbing brush and glove replacement schedule was in place.

We found a number of shortfalls that remained outstanding from our previous inspection:
The practice was unable to assure themselves that the sharps injury workplace occupational health department contact details were correct.
Not all the clinical staff, working on the day of our visit, adhered to bare below elbow, footwear and hair management protocols in line with national infection prevention and control guidance.
Evidence to confirm staff had oversight of cleaning standards was not available.

We also found a number of additional shortfalls:
Wet cleaning mop heads and buckets were stored in a first-floor cupboard. Cleaning equipment must always be stored completely dry to prevent bacterial growth.
Treatment room 1 contained a box of non-CE/UKCA marked surgical sutures. Surgical sutures are classified as regulated medical devices. Using non-CE/UKCA marked sutures is illegal and poses potential patient safety risks. The box was disposed of during our visit.
Surgery 1 contained a material covered guest chair which made effective cleaning a barrier. The provider told us they would remove this from the room as soon as practicably possible.

A general waste bin situated in the staff changing room contained clinical personal protective equipment (clinical gloves and masks).
Bottles of purified water were stored in the decontamination room. The practice did not have a protocol in place to ensure bottles were emptied at the end of each day.

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