Marble Arch Dental 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 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 adequacy and availability of emergency equipment and medicines, and the standards of infection prevention and control, including the management of clinical waste.

We also found concerns relating to recruitment, as well as the training, support and development provided to staff.

In addition, we found concerns relating to staff’s understanding, knowledge and awareness of safeguarding and there was a lack of learning culture at the practice.

These concerns were in breach of Regulation 12, Safe care and treatment; Regulation 13, Safeguarding service users from abuse and improper treatment; Regulation 17, Good governance; Regulation 18, Staffing and Regulation 19, Fit and proper persons employed.

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 practice did not have safeguarding processes in place and staff were unaware of their responsibilities for safeguarding vulnerable adults and children.

The practice did not have information available to staff in relation to safeguarding vulnerable adults and children.

Staff were not aware of how safeguarding information could be accessed, they did not know who the safeguarding lead was at the practice and did not know how to escalate safeguarding concerns within the practice and externally.

The practice did not ensure that staff completed safeguarding training to the appropriate level or updated their training at appropriate intervals. Evidence of training was only seen for 3 members of staff.

There was no evidence that new staff received an induction, ensuring new staff were familiarised with any safeguarding arrangements.

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 identify and manage risks effectively. The practice had not completed a health and safety risk assessment or a sharp’s risk assessment. Staff did not have access to a safer sharps system to reduce the risk of sharps injury. In addition, 2 staff members had sustained sharps injuries in June 2024 and May 2025, and the practice had not taken steps to assure themselves that they had adequate immunity to Hepatitis B.

Staff could access emergency equipment and medicines, but these were not checked in line with national guidance. The medical emergency kit did not contain all items as advised by Resuscitation Council (UK), and some of the items had expired in 2018.

We were not assured that staff could effectively respond to a medical emergency, as not all staff knew where the medical emergency kit was located. Staff training records showed that only 3 of the 20 staff members had completed training in emergency resuscitation and basic life support in the year preceding our inspection, and staff did not participate in medical emergency scenario practices.

Hazardous substances were not stored safely. Bleach and cleaning products were stored within an unlocked cupboard and could be accessed by patients, and the practice had not completed risk assessments for the hazardous materials in use at the practice, in line with Control of Substances Hazardous to Health (COSHH) regulations.

We did not see satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. The practice was unable to provide evidence to demonstrate the compressor and air conditioning units had been serviced in line with guidance.

The practice had ineffective arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was not 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.

We were not provided with evidence of any performance checks or servicing of the intra-oral X-ray units or cone-beam computed tomography (CBCT) since 2021. In addition, the service had not appointed a radiation protection advisor (RPA) and medical physics expert (MPE) or notified the Health and Safety Executive that they were working with radiation generators. Following feedback from the inspection team, the practice sent evidence that they had appointed an RPA and MPE on 11 September 2025.

The practice did not manage fire safety well. A fire risk assessment had last been completed in June 2020, and we did not see evidence that all the actions detailed in the action plan had been acted upon. This included, but was not limited to, ensuring there were an appropriate number of staff trained to act as fire wardens and to maintain a fire logbook ready for inspection.

We could not be assured that the fire safety equipment at the practice was in good working order, as there were no records of servicing of the fire extinguishers and no evidence of routine in-house checks of the fire alarm, emergency lighting and fire extinguishers. While fire exits were clear and well signposted, we saw no records to demonstrate that staff had performed fire drills or had received training in fire safety. Following feedback from the inspection team, the practice provided evidence that they had taken action to address these concerns relating to fire safety.

The practice had systems for appropriate and safe management of medicines.

The practice’s recruitment policy and procedures did not reflect relevant legislation, to help them employ suitable staff, including agency or locum staff. The practice had not taken sufficient measures to assure themselves that all staff were fit and proper, including failing to carry out appropriate levels of Disclosure and Barring Service (DBS) checks, right to work checks, and verification of photographic identification.

In addition, the practice did not consistently assure themselves that clinical staff had immunity to Hepatitis B. Of the 5 dental nurses working during the week of our inspection, only 2 had records of their Hepatitis B vaccination. Both were still at vaccination stage and had not yet achieved full immunity. There was no risk assessment in place to mitigate the risks associated with this. The practice did not hold evidence of immunity to Hepatitis B for any of the associate dentists.

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

We were not assured that all staff had the skills, knowledge and experience to carry out their roles. Staff who we spoke with were not confident on how to recognise suspected sepsis and how to deal with it. In addition, they did not demonstrate a good knowledge of safeguarding.

The practice did not ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. The practice held records of training for only 3 staff members, (the practice manager, the registered manager and 1 associate dentist). We were unable to see evidence of training for all other staff, including but not limited to, training in fire safety, medical emergencies, radiology, training in how to interact appropriately with people with a learning disability and autistic people, and safeguarding training to a level appropriate to their role.

As the practice did not conduct annual appraisals, staff did not have any opportunities to discuss their learning needs, general wellbeing and aims for future professional development. Ongoing informal discussions between staff and the practice manager were via instant messaging on a mobile phone application.

The practice ensured clinical staff were qualified and registered with the General Dental Council.

The practice’s infection control procedures did not reflect published guidance.

Decontamination of dental instruments was not in line with guidance from the Department of Health publication ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM01-05). The practice did not have safe procedures for the transfer of contaminated items from the treatment room to the decontamination facility. The temperature of the water used for manual cleaning of contaminated dental instruments was not monitored. There were no systems and processes to monitor the use of long handled brushes used for manually cleaning the instruments. There were no heavy-duty gloves available for staff to wear during the manual cleaning process. Pouching of the decontaminated dental instruments was found to be inconsistent.

Equipment was not always maintained and serviced in line with manufacturers’ instructions.The last in-house testing records of the autoclaves were from June 2025, and on the day of inspection, the printer for the autoclave was out of ink.

The practice did not ensure that staff had received appropriate infection prevention and control training. Staff who we spoke with did not have robust knowledge and awareness of infection prevention and control processes.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. However, we could not be assured that the practice was monitoring and implementing the recommendations from the last Legionella risk assessment.

The practice did not have protocols to ensure effective environmental cleaning. The cleaner was not provided with cleaning logs and did not have access to appropriate colour coded cleaning equipment which aids in avoiding cross contamination.

We could not be assured that clinical waste was segregated and disposed of correctly. The practice had not had any clinical waste collected in the 3-months preceding the inspection. The inspection team noted that used gloves and other waste from the treatment rooms were disposed of in domestic waste bags.

The practice had not completed infection prevention and control audits in line with current guidance.

We saw, and staff confirmed that single-use items were not reprocessed.

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