James Hehir Building

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 most risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working. Since the new management team had joined the practice in November 2025, they were in the process of reviewing all areas of risk and were working through an action plan to ensure these were effectively managed.

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 knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Improvements could be made to ensure that all emergency equipment including masks and needles were available and the storage of medicines such as Glucagon, a medicine used to treat very low blood sugar, is in line with guidance. The practice immediately replaced all out of date and missing equipment and medicines.

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.

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 management of fire was overseen by the University Estates department. The practice mostly managed fire safety well, and fire exits were clear and well signposted. We noted evacuation chairs were located on each landing should the lifts fail. However, staff within the practice were not able to confirm when a fire drill had taken place and were unsure how to use the evacuation chairs. We discussed this with the practice management team who confirmed this would be reviewed and acted upon.

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.

The practice had a recruitment policy and procedures that reflected relevant legislation which were overseen by the University Human Resources department, 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.

Newly appointed staff had an appropriate role specific structured induction.

Staff had the skills, knowledge and experience to carry out their roles. We were told the practice was in the process of recruiting additional staff including reception staff. 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.

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

Processes to support and develop staff with additional roles and responsibilities were being reviewed. Staff discussed their learning needs, general wellbeing and aims for future professional development during clinical supervision and ongoing informal discussions. We were told these had been limited. However, we were told the interim practice management team had reintroduced one-to-one and practice team meetings and planned to reinstate annual appraisals.

Staff told us they were proud to work in the practice, but had some frustrations over staff turnover in the past.

The practice had infection control procedures that mostly reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of most 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 procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. Many of the processes were undertaken by the Universities Estates department. However, we noted monthly water temperature checks had not been undertaken by the practice since July 2025 and the practice were not aware of any testing undertaken by the estates team. We discussed this with the management team and were assured these would be reinstated by the practice team.

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. We noted the data loggers from the practice autoclaves were not being downloaded, therefore the practice could not be assured that sterilization had reached the required temperatures and pressures for regulatory compliance. We discussed this with the practice team and were assured that these would be put in place in line with current guidance.

The practice showed us an infection prevention and control audit, however these were not regularly completed. Following the inspection, the management team confirmed these would be completed 6 monthly in the future.

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