Cathedral 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.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 10 April 2025.

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 inspection on 18 November 2025, we found the practice had made the following improvements to comply with the regulations:

The practice had effective processes to identify and manage risks. Risk assessments for the use of sharps and lone working had been implemented and a new fire risk assessment undertaken with the relevant recommendations actioned.

Improvements had been made to ensure the management of fire safety was effective. A new fire detection system had been installed, and periodic testing and checks of the alarm system, emergency lighting and fire extinguishers were completed. Additional improvements had been made to the signposting of emergency exits and the recording of evacuation drills.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely, and improvements had been made to ensure these had up to date risk assessments and safety data sheets accessible to staff, in line with Control of Substances Hazardous to Health (COSHH) regulations 2002.

The practice had reviewed their systems for appropriate and safe management of medicines to ensure anti-microbial prescribing guidance was followed.

At the inspection on 18 November 2025, we found the practice had made the following improvements to comply with the regulations:

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. Improvements had been made to ensure information relevant to staff employment in their role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was available. However, improvements were ongoing to ensure complete and detailed records were maintained for all staff.

Improvements had been made to the arrangements to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals.

Staff had the skills, knowledge and experience to carry out their roles, and were able to demonstrate this. They told us that there were enough staff on duty at all times.

The processes to support and develop staff with additional roles and responsibilities had been reviewed. Appraisals and 1 to 1 meetings for staff to discuss their learning needs, general wellbeing, and aims for future professional development were well documented

At the inspection on 28 October 2025, we found the practice had made the following improvements to comply with the regulations:

The practice had infection control procedures that reflected published guidance and were being followed.

Staff had received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

The decontamination room had been de-cluttered and the process of decontamination of dental instruments aligned with national guidance. Some improvements were still underway to ensure all dental instruments were pouched and stored safely following decontamination.

The practice had made improvements to the procedures in place to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment had been completed in line with current guidance, and the recommended control measure of recording water temperature checks was being completed. Improvements are ongoing to address the low temperatures identified at one tap.

The practice had made improvements to the process of completing infection prevention and control audits, which were reflective and aligned with current guidance.

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