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 not providing safe care in accordance with the relevant regulations.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 5 December 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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.

At the inspection on 24 February 2026 we found the following concerns:

Staff could access emergency equipment and medicines that were checked 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 face to face medical emergency training for both staff members.

The practice had arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was available.

Fire training and drills were carried out by staff. A fire safety risk assessment was completed in January 2026 which identified areas for improvement. The provider stated the fire alarm was repaired following our inspection on 5 December 2025 however, it was reported that a sensor was faulty. This had not been addressed at the time of our follow up inspection.

An Electrical Installation Condition Report (EICR) was completed in January 2026 which was recorded as unsatisfactory. An electrician was arranged to carry out the required work after our follow up inspection.

A gas service and report had been completed in December 2025.

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. Staff had carried out the recommended training in safeguarding vulnerable adults and children.

A comprehensive Legionella risk assessment had been undertaken by a trained and competent individual. Areas of improvements were identified. We were provided with a water temperature testing log for December 2025 which demonstrated adequate hot water temperature measurements. There were no records of water temperature testing for January 2026 or February 2026. We found there was no hot water in the decontamination room or the treatment room due to faulty water heaters. At the time of our follow up inspection, a plumber was contacted and arranged to attend the practice the following day to quote on carrying out the required repairs.

We found that clinical waste was not managed in accordance with the relevant regulations, taking into account the guidance issued in the Health Technical Memorandum 07-01. We found there was no contract in place for the waste collection to confirm the provider had an agreement with an authorised waste carrier, as required under the Environmental Protection Act 1990 and HTM 07-01. Following our follow-up inspection a contract was put in place.

We found there was damaged seating in the patient waiting room and the treatment room which required re-upholstering and staining to the carpet. The flooring in the treatment room required replacing. This was identified at the inspection on 5 December 2025.

We found there was a lack of Control of Substances Hazardous to Health (COSHH) risk assessments available to all staff. The Control of Substances Hazardous to Health Regulations 2002 (COSHH) defines the legal requirements for providers to protect the health of people in the workplace from hazardous substances. COSHH risk assessments with links to safety data sheets were stored on the providers laptop which the trainee dental nurse did not have access to.

The judgement for Safe and effective staffing is based on the latest evidence we assessed for the Safe key question.

The judgement for Infection prevention and control is based on the latest evidence we assessed for the Safe key question.

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