Bullsmoor 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. On the day of the inspection, a risk assessment to identify and mitigate risks associated with lone working was not available for review. However, the practice submitted this document following the inspection.

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 that were checked in line with national guidance. 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.

The practice used an external seditionist to administer intravenous sedation. Training records were not available for all staff, treating patients under sedation, in immediate life support (ILS) training (or basic life support training plus patient assessment, airway management techniques and automated external defibrillator training). In response to our inspection feedback the practice provided evidence that ILS training had been arranged for all staff involved in the provision of intravenous sedation. Furthermore, the practice confirmed that intravenous sedation services would not be resumed until the required training had been completed.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

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. This included cone-beam computed tomography (CBCT), laser and handheld X-ray equipment.

The practice managed fire safety well, and fire exits were clear and well signposted. Fire safety equipment was serviced regularly and the practice carried out periodic in-house fire safety checks and fire evacuation drills. The Fire Risk Assessment dated 27 February 2025 identified some recommendations. Not all of these had been actioned. The practice manager told us that they would seek further clarification on these recommendations from a fire safety expert.

The Electrical Installation Condition Report (EICR) dated 25 October 2021 was marked ‘Unsatisfactory’, with a number of recommendations requiring urgent action. Following the inspection, the practice provided further documents demonstrating that the necessary remedial works had been completed. A new EICR had been scheduled for 20 October 2025, and this was marked as ‘Satisfactory’.

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

The practice had a recruitment policy and procedures that broadly reflected relevant legislation, to help them employ suitable staff, including agency or locum staff Improvements should be made to ensure the practice consistently retained satisfactory evidence of conduct in previous employment concerned with the provisions of services relating to health and social care or children and vulnerable adults, for all members of staff.

Some clinical staff did not have documented evidence of their hepatitis B vaccination response. Following the inspection, the practice provided confirmation that one individual had scheduled a blood test, and risk assessments were completed for the others, outlining control measures to be followed while awaiting test results.

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

Newly appointed staff had an appropriate role specific structured induction.

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 effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, one-to-one meetings, practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “The leaders in the practice are approachable and open to communication. They encourage a supportive environment where team members feel comfortable sharing ideas, raising concerns, or asking questions.” Another staff member said, “Having worked at three other practices before working here full-time and having visited many other practices, I can say that this is an amazing clinic to work at. Yes, there will always be an issue here and there but on the whole, we are a family, we work well together and if everyone has the same goal - to ensure we are providing the best for our patients - then there is a common goal, everyone is on the same page.”

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 effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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.