York Road 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 not providing safe care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider has made the required improvements.

During our inspection of this key question, we found concerns related to

the safety of the premises, the management of risks associated with fire and

safe and effective staffing.

These concerns resulted in breaches of Regulations 12 (Safe care and treatment) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the detailed findings below.

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 did not have effective systems in place to assess and manage the fire-related risks. A fire risk assessment had not been carried out. Staff told us that the practice relied on the company responsible for the annual servicing of the fire extinguishers to highlight any fire safety issues. In response to our inspection feedback the provider informed us that they had commissioned an external fire risk assessment for 21 July 2025.

There were no records to show that the practice carried out regular in-house testing of the fire detection and warning systems to ensure that they were operational and effective in alerting staff and patients in the event of fire.

Fire escape routes were not clearly signposted. We further noted that the door leading from the staff room to the back garden was signposted as a fire exit, but it was locked and obstructed at the time of the inspection. The practice was also unable to demonstrate that they had assessed whether emergency routes and exits required illumination. Following the inspection, the practice submitted photographic evidence showing that the rear fire exit was no longer locked or obstructed.

We observed extensive use of extension leads, some of which were connected to what appeared to be a loose wall socket. Staff were unable to demonstrate that this issue had been identified or that appropriate control measures had been implemented to mitigate the risks associated with the use of extension cables and potentially damaged electrical sockets.

An Electrical Installation Condition Report (EICR), which confirms whether the condition of fixed electrical installations within the premises is satisfactory, had not been carried out. Following the inspection the provider told us that the EICR had been booked for 22 July 2025.

The Portable Appliance Testing report dated 5 September 2023, identified several items that had failed safety checks. However, there was no documentation to confirm that these had been removed from use. In response to our inspection feedback, the provider told us that these had now been removed from use.

On the day of the assessment, a valid gas safety certificate was not available for review. We noted a maintenance record dated 2 September 2024, which detailed remedial work to address a gas leak issue. However, the document stated that it should not be used as a gas safety record. We brough this to the provider`s attention and following the inspection they provided a gas safety certificate dated 10 July 2025. Overall, we were not assured the core safety checks and services had been carried out in a timely manner to ensure the premises were safe.

Staff knew how to respond to a medical emergency and most of them had completed training in emergency resuscitation and basic life support every year.

Emergency equipment and medicines were not always available in accordance with national guidance. On the day of the assessment there were items missing from the emergency kit. We brought this to the providers attention, and they took immediate action by placing an order for these items. Overall, improvements were needed to ensure that weekly checks of the medical emergency equipment were effective to identify if any items that were not available in line with current guidance.

The premises were visibly clean and free from clutter. Hazardous substances were clearly labelled and stored safely. However, the practice had not carried out risk assessments to minimise the risks that could be caused from the substances hazardous to health, and safety data sheets were not accessible to staff. Following the inspection the provider told us that risk assessment for each hazardous substance used in the practice had now been completed and that safety sheets were accessible to staff.

We saw satisfactory records of servicing and validation of the dental 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.

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 that reflected relevant legislation. However, one staff member did not have an enhanced Disclosure and Barring Service (DBS) certificate on file, as required by the relevant regulations. Additionally, a risk assessment had not been completed to address the absence of a valid DBS check. The provider told us that they had submitted the DBS application a month prior the inspection and it was currently pending.

Two clinical staff members did not have evidence of receiving their 3rd Hepatitis B vaccination, and one clinical staff member was unable to demonstrate their Hepatitis B immunity status. There were no records to show that the provider had assessed the risks associated with staff who were unvaccinated or whose immunity was unknown. Following the inspection, the provider told us that the relevant staff members had booked their appointments for their final Hepatitis B vaccination and the blood tests to confirm their immunity levels.

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 training, including continuing professional development, was up-to-date and reviewed at the required intervals for most staff members. However, on the day of inspection one member of staff did not have evidence of training in core subjects, including infection prevention and control, safeguarding, autism and learning disability awareness. Following the inspection the provider submitted additional training certificates confirming that the staff member had now competed training in these areas.

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.

The practice had infection control procedures that broadly reflected published guidance. However, we have identified some areas requiring improvement.

Although a dedicated decontamination room was available, the practice did not ensure that there was a clear physical separation between decontamination and clinical procedures. Contaminated dental instruments were scrubbed and disinfected in the treatment rooms. We brought this to the provider`s attention and they made immediate changes by ensuring that all stages of instruments reprocessing were carried out in the decontamination room.

The practice could not demonstrate that required checks were being carried out on decontamination equipment in accordance with the manufacture`s guidance or, in the absence of this, in line with published guidance. Following the inspection the provider told us they had sought advice and these tests were now being carried out.

Most staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

Staff used personal protective equipment 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. Improvements could be made to ensure the audits were suitable to drive improvement and picked up issues, such as the lack of equipment checks and decontamination of instruments in the clinical area, as identified by the inspection team.

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