Egremont Smile Centre

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 relates 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 had arrangements to ensure the required radiation protection information was available.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

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

The practice had processes to identify and manage risks. However, these were not always effective.

The equipment in use had been recently serviced. We could not be assured from the records available that the system in place to ensure they were maintained as per manufacturers’ instructions was effective. For example, records indicated a number of pieces of equipment had not been serviced annually as recommended.

Staff told us NHS prescription pads were kept secure, and a log was in place to monitor and track their use. However, this was not effective. From the records we were shown the practice could not account for all prescriptions.

Systems and processes for oversight of fire safety were not working effectively. A fire safety risk assessment was carried out in April 2025 in line with legal requirements. However, the practice could not fully demonstrate the risks had been assessed by someone competent to do so. The practice should take action to appoint a competent person, to carry out any preventive and protective measures, taking into account The Regulatory Reform (Fire Safety) Order 2005. The provider confirmed a new fire risk assessment had been arranged to be carried out shortly after the inspection.

Improvements should be made to the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure the products are stored securely. We discussed with the practice manager the importance of ensuring hazardous substances are stored segregated from materials used for treatment. Staff described the protocols in place for the management of substances hazardous to health. We noted safety data sheets and risk assessments for products were available. However, we could not be assured these would be easily accessible in the event of an incident.

The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. Improvements were needed to ensure these were followed. We looked at several staff files and noted Disclosure and Barring Service (DBS) checks or appropriate risk assessments were not consistently carried out at the point of recruitment. Improvements were needed to the systems to ensure clinical staff had received appropriate vaccinations, including the vaccination to protect them against the Hepatitis B virus, and that the effectiveness of the vaccination was checked. Records were not available for all clinical staff to show that they had sufficient immunity against the Hepatitis B virus. There was no evidence the risks of this had been considered. Satisfactory evidence of conduct in previous employment was also not available for all staff members.

The practice ensured clinical staff were qualified, registered with the General Dental Council and clinicians had appropriate professional indemnity cover. Immediately after the inspection, we received confirmation that trainee dental nurses were also indemnified.

Newly appointed staff had an appropriate role specific structured induction.

On the whole, staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children.

Systems and processes for oversight of completed staff training were not working effectively. Records available showed most training had been undertaken immediately before the inspection. The system failed to demonstrate that staff completed training at required intervals prior to this. Staff who had recently carried out training in areas such as sepsis awareness and consent lacked understanding of these areas. In addition, there were gaps in oversight that meant up-to-date training records were not available for all clinical staff members in relation to radiation protection.

Staff discussed their general wellbeing during practice team meetings and ongoing informal conversations.

Staff we spoke with on the day stated they felt supported and valued, and they enjoyed working in the practice.

The practice had infection control procedures which reflected published guidance. However, systems and processes to enable sufficient oversight to ensure these were always followed were not effective. The practice had an infection prevention and control (IPC) audit available that was recently completed, but this did not highlight the shortfalls observed during the inspection. Improvements were needed to ensure IPC audits were completed in accordance with current guidelines to drive the required improvements.

We could not be assured the arrangements to provide staff training and supervision in IPC processes were effective.

Decontamination of used dental instruments was not always in accordance with recognised guidance. Staff could not demonstrate that the manual cleaning solution was used in accordance with the manufacturer’s guidance. Extractor fans to enable the correct air flow in the decon room were not working.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment carried out on 2 April 2025. The practice were not able to demonstrate the risks had been assessed by someone competent to do so. Monthly water temperature monitoring was carried out as part of the Legionella management protocols. However, we could not be assured the temperatures were being recorded at the recommended outlets. In addition, some outlets were significantly higher than recommended and no action had been taken to mitigate the risk of scalding. The washer-disinfector was plumbed in but no longer in use and no flushing arrangements were in place. We noted that while there was a protocol in place for flushing the dental unit waterlines, the product used to maintain them was not used according to the manufacturer’s guidance to ensure its efficacy.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste however these were not effective. We observed clinical waste bags were stored in a storeroom that was accessible to the public and the storage bins were overflowing and not secure.

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