BIRMINGHAM DENTAL EXCELLENCE

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, sepsis awareness and lone working.

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. Although we noted that one staff member was overdue to complete this training. Evidence was sent following this inspection to demonstrate that this 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. However, we saw that electromechanical servicing had not been completed on the intra oral X-ray machines. Following this inspection, we received written assurance that this was scheduled to take place on 15 January 2026. We saw that the required radiation protection information was available. This included cone-beam computed tomography (CBCT).

The practice had some systems to manage fire safety. The fire alarm had not been serviced at the required frequency. Following this inspection, we received confirmation that a further fire alarm service was booked for 21 January 2026. We were assured that the fire alarm would be serviced 6 monthly going forward. Fire exits were clear and well signposted. We were told that the fire alarm and emergency lighting were checked weekly and saw a diary entry to remind staff to do this. There were no other logs to demonstrate checks made on fire safety equipment such as fire extinguishers, fire doors or fire exits in accordance with the fire risk assessment. Following this inspection, evidence was sent to demonstrate that staff had received training regarding how to complete fire safety checks and the log on the compliance system was now being completed.

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 agency or locum staff.

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

There was insufficient documentary evidence to demonstrate that all newly appointed staff had an appropriate role specific structured induction. We saw evidence to demonstrate that probationary meetings were held with newly employed staff. Following this inspection, we were sent evidence to demonstrate that all staff had received an induction to the practice.

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. We were told that going forward, staff would discuss their learning needs, general wellbeing and aims for future professional development during annual appraisals. Nursing and reception staff at the practice were newly employed and were not yet due for an annual appraisal. We saw that probationary meetings had been held with newly employed staff. We saw that monthly ‘huddle’ meetings were held and staff said that they could have an informal discussion with the provider if they needed to.

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 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.