Great Cornard 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 not providing safe care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breach we found at our inspection on 27 January 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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 22 January 2026, we found the practice had made some improvements, however these were neither embedded nor sufficient to comply with the regulation:

Safeguarding processes were in place; all staff were aware of their responsibilities for safeguarding and had completed training.

We reviewed the arrangements to ensure the safe management of Legionella in the practice. We were provided with a Legionella risk assessment undertaken on 19 February 2025 identifying the risks associated with bacteria developing in the waterlines. Although we were provided with a water temperature testing log, we were not provided with evidence that daily flushing of dental unit water lines were carried out. We were not assured that systems were in place to remove stagnant water, reduce high microbial counts and clear out biofilm build up that accumulates in narrow tubes overnight of between patients. We noted 18 high risk actions and 8 medium risk actions that had not been undertaken.

We observed limescale residue on the tap outlets in the ground floor decontamination room.

The practice had recently undergone building development including the introduction of a new treatment room and changes to the plumbing within the practice. The change in the plumbing system and the lack of action taken from the 2025 risk assessment indicated that the legionella risk assessment was no longer representative of the premises and not in line with the recommended guidance HSE Approved Code of Practice (ACoP) L8 – Legionnaires’ disease: The control of legionella bacteria in water systems and HTM 04‑01 (Safe water in healthcare premises).

The second gas boiler in the kitchen area had not been serviced in line with manufacturers guidance.

There was no practice-based health and safety risk assessment in place.

The sharps risk assessment had not been amended to ensure it reflected the processes in place at the practice, conventional sharps were still being used and there was no needle guard or other safety device to prevent injuries available in the treatment room.

Training records reviewed did not show evidence that any of the staff had completed fire awareness training. Additionally, emergency fire evacuation plans including identifying the needs of vulnerable people using the service, had not been completed.

Information from the autoclave data logger was not being consistently downloaded, recorded or reviewed in line with the manufacturer’s guidance. Records indicated that responsibility for recording the information in the logbook was not present across the team. This information was not recorded daily when the autoclave was in use.

There were no schedules or logs to demonstrate cleaning of the dental practice including the reception, waiting room, decontamination room and patient/staff toilet. We were told that staff undertook the cleaning of the practice.

We observed dust on surfaces in the reception area and dust and grit on the floor where building work had been undertaken in reception.

We observed dust and grit on surfaces in the decontamination room under cupboards and the handwashing sink where drilling in walls had been undertaken.

Surfaces in the decontamination room were cluttered which would not enable effective cleaning to maintain infection prevention and control standards.

We noted cleaning equipment such as mops were sitting in a shower tray and not stored in line with guidance to help reduce cross contamination.

We noted there were no checks undertaken on the ultrasonic bath and logs of checks in the decontamination room were not being recorded regularly. We identified these areas at our inspection in January 2025. When we discussed this with the staff at the inspection in January 2026, we were told they were still not aware these needed to be done.

Although some COSHH risk assessments had been completed, most data sheets were outdated documents from the previous provider and had not been reviewed or updated as Great Cornard Dental Practice. Several assessments were incomplete, and the practice could not confirm that risk assessments existed for all products in use. We also observed hazardous items, left unsecured in the kitchen and decontamination areas.

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