Nunneleyhouse 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 providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

Although 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.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice however, this was not always reflected in our findings.

The practice had processes to identify and manage some risks. We identified concerns with the assessment of risks and management of fire, electrical safety, waste management and the control of substances hazardous to health (COSHH).

Staff could access emergency equipment and medicines that were checked however, this was not in line with national guidance. Staff knew how to respond to a medical emergency and had completed on-line training in emergency resuscitation and basic life support. Following our inspection the provider made arrangements to have in-house face to face medical emergency training for both staff members.

In addition, Glucagon (a medicine used to manage low blood sugar) was stored in a fridge but staff did not monitor the temperature of the fridge to ensure the medicine was stored at the manufacturer’s recommended temperature.

Hazardous substances were stored safely. COSHH risk assessments and safety data sheets required strengthening.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had some arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was not available at the time of our inspection. 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 practice did not manage fire safety well. The practice could not demonstrate that a comprehensive fire safety risk assessment had been undertaken by a trained and competent individual, and the fire alarm was said to be faulty. No fire training or fire drills were carried out by staff. Following our inspection, the fire alarm was repaired, and an external fire safety risk assessment was arranged for January 2026.

We were not provided with a copy of an Electrical Installation Condition Report which should be carried out every 5-years.

There was no gas safety record available at the time of our inspection. A gas service and report was carried out following the inspection.

Whilst these issues were present, our concerns related to lack of governance and risk oversight, rather than immediate patient and staff safety.

The practice recruitment procedures did not fully reflect relevant legislation. Improvement was required to ensure the provider checked all information in respect of persons employed or appointed for the purposes of a regulated activity as set out in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was no evidence to show staff had adequate immunity to Hepatitis B. Following our inspection, arrangements were put in place for staff to have a Hepatitis B vaccination and a risk assessment was carried out.

Arrangements to ensure staff training was up-to-date and reviewed at the required intervals was not in place.

Newly appointed staff did not have an appropriate role structured induction.

Staff demonstrated some 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.

At the time of our inspection, we found staff had not carried out the recommended training in safeguarding vulnerable adults and children. Evidence was submitted following our inspection demonstrating this had been completed at the required level for their role.

There were limited processes to support and develop staff with additional roles and responsibilities within the practice. Staff discussed their learning needs, general wellbeing and aims for future professional development during ongoing informal discussions.

Staff used personal protective equipment in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice had infection control procedures but these did not reflect published guidance.

Processes for sterilisation of dental instruments required improvements as they did not reflect guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices. We found pouched instruments that had exceeded their 12-months expiry date and dental materials that were out-of-date.

Staff received some training and demonstrated some knowledge and awareness of infection prevention and control processes.

The practice could not demonstrate that a comprehensive Legionella risk assessment had been undertaken by a trained and competent individual. The practice procedures to reduce the risk of Legionella, or other bacteria, developing in water systems required strengthening. We found improvements should be made in the recording of hot and cold water temperatures to ensure they were within the required range. This was addressed immediately following our inspection. We observed scale deposits on the outlets of all the taps. Following our inspection, a Legionella risk assessment was carried out.

We found shortfalls with protocols to ensure effective cleaning and the safe segregation and disposal of hazardous waste. The premises were not well maintained and required attention. In particular, the wall in the staff kitchen and areas in the decontamination room were visibly unclean and carpeting in the waiting area and treatment room required attention. Storage of clinical waste required improvements and there was no contract available for collection of the clinical waste.

The practice completed infection prevention and control audits in line with current guidance. However, we found there was no action plan in place to address the shortfalls identified.

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