Smile Creator 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

We found this practice was providing safe care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

Whilst there are issues to be addressed, the impact of our concerns relate to the governance and the oversight of the risks, rather than a patient safety risk.

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, sepsis awareness and lone working. We noted that the health and safety and sharps risk assessments did not reflect our findings on the day. We discussed this with the provider, and they submitted evidence that new risk assessments were completed on 13 March 2026. We also noted the sharps injury poster needed to be updated to reflect protocols for the practice if a sharps injury occurred. The provider acted immediately and created a new injury process on 13 March 2026.

Staff demonstrated an open culture in relation to people’s safety.

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 premises were visibly clean, well maintained and free from clutter.

Hazardous substances were clearly labelled and stored safely. However, the practice had not carried out risk assessments in relation to the safe storage and handling of all the substances hazardous to health. In addition, the practice and staff had limited access to relevant Safety Data Sheets. We discussed this with the provider, who assured us that the required risk assessments and documentation would be completed and made accessible to staff within the next 4 weeks.

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.

Improvements were required to the oversight and management of fire safety. Fire extinguisher visual checks were not logged and there was no evidence of a fire drill ever being carried out. The provider acted immediately and created a log for the fire extinguisher checks and carried out a fire drill on 13 March 2026. Fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

Staff 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. However, they were unclear of their responsibilities regarding the oversight of Was Not Brought within the practice. Was Not Brought is a code for when a child or an adult, who is reliant on another person to get an appointment, has missed their appointment. Missed appointments can be a sign of neglect and therefore providers should have appropriate safeguarding systems and processes to monitor and have oversight of missed appointments, particularly for children and vulnerable adults.

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.

We noted that environmental cleaning logs were not consistently completed. We discussed this with the provider who assured us this would be addressed and improvements made.

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 did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A legionella risk assessment was carried by a competent person out on 19 January 2023, it was then repeated on 4 March 2026 and the same issues and recommendations were highlighted which were also identified as a concern on the inspection day. The 2023 risk assessment recommended removing a disused washer disinfector from the decontamination room, which was present during our visit on 12 March 2026. The risk assessments highlighted that temperatures for some taps within the practice were not reaching the required temperatures. We noted during our visit on 12 March 2026 that the hot water temperature was not meeting the required level, as described in both Legionella risk assessments. We discussed this with the provider and new hot water temperature checks were carried out by a plumber on 15 March and the hot water was at the correct temperature. The practice was in the process of addressing recommendations documented in a recent external risk assessment.

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.