Spirit of Excellence 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 line 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.

The practice identified and managed risks effectively and staff described the processes. This included sharps safety and sepsis awareness.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and this was reflected in our findings.

Staff could access emergency equipment and medicines. They told us that they were checked weekly; however, they did not have evidence to confirm this. Following feedback, the practice introduced a log. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff also participated in medical emergency scenario training.

Staff providing treatment to patients under sedation had completed basic life support training plus patient assessment, airway management techniques and automated external defibrillator training.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. However, the provider had not ensured risk assessments were completed for substances hazardous to health used within the practice and safety data sheets were not available to staff.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. The most recent risk assessment completed in 2025 by the Radiation Protection Advisor recommended the relocation of the isolator switch and the fitting of rectangular collimators. These actions had not been completed at the time of inspection; however, evidence received following the inspection confirmed that the required actions had been satisfactorily addressed. We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings.

The practice management of fire safety needed improvements in line with the most recent fire risk assessment. At the time of inspection, there were faults with the fire alarm system and the emergency lighting. We received evidence that these have been repaired. There was firefighting equipment which received annual servicing and fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff including visiting clinicians.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

We did not see documentation to demonstrate that newly appointed staff received a structured, role-specific induction. However, the practice informed us that no new staff had been recruited in over 10 years.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were processes to support and develop staff with additional roles and responsibilities, for example, the dentist told us that training would be offered to the dental nurse to assist with the day-to-day practice compliance. Staff discussed their learning needs, general wellbeing and aims for future professional development informally.

Staff felt respected, supported and valued, and they were proud to work in the practice.

The practice had infection control procedures that reflected published guidance.

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

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, improvements were needed to ensure records of hot and cold-water temperature checks were appropriately maintained and that infrequently used outlets were routinely flushed. We observed that the sensor-operated handwashing basin in the decontamination room was malfunctioning, which increased the risk of bacterial growth. The provider told us that repairs had been arranged; however, sourcing the required parts had proved difficult

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

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