Kings Heath Dental

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 infection prevention and control standards not being followed at the practice

the adequacy and availability of emergency equipment and medicines

lack of evidence to demonstrate staff could safely carry out emergency resuscitation and basic life support

radiation safety procedures

These concerns were in breach of Regulation 12, Safe care and treatment.

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 identify and manage all risks effectively.

Systems for checking emergency equipment and medicines were not effective as they had not identified that items of medical emergency kit were missing or out of date. The adrenaline (x2) expired in January and June 2025, the Aspirin (x2) expired in March and April 2025, the Glucagon expired in October 2020, the Glucose expired in March 2025, and the adult size oxygen mask expired in February 2015. Missing items were sizes 0, 2 and 3 clear face masks and eye wash. The provider sent us evidence they had ordered these items immediately following the inspection.

The oxygen cylinder had no service history, no expiry date and no checks or logs in place.

Staff had not completed training in emergency resuscitation and basic life support. The provider sent evidence a training course had been scheduled following the inspection.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We did not see satisfactory records of servicing and validation of all equipment in line with manufacturer’s instructions. The Electrical Installation Condition Report (EICR) was dated 22 June 2019. EICR’s are required every 5 years. Following the inspection, the provider informed us they had scheduled an electrician to carry this out on 5 August 2025. The gas safety certificate was dated May 2024. This should be conducted annually. The provider sent us evidence a gas safety inspection had been carried out on 11 August 2025, following the inspection.

The practice did not have all the required arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was not available. The provider had not registered with the Health and Safety Executive (HSE), had not appointed a Radiation Protection Advisor/Medical Physics expert (RPA/MPE) or a Radiation Protection Supervisor (RPS). Local rules outlining key working instructions to help minimise the risks associated with the use of X-ray radiation during dental radiography were not in place and appropriate signage was not on doors where X-ray machines were located. The provider sent us evidence they had addressed these findings following the inspection.

The practice mostly managed fire safety well, and fire exits were clear and well signposted. We discussed the requirement for carrying out and recording fire evacuation drills and fire alarm tests should be carried out weekly rather than monthly.

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

Although the practice had a recruitment policy and procedure that reflected relevant legislation, to help them employ suitable staff, the provider did not follow this. On the day of the inspection we were provided with Disclosure and Barring Service (DBS) dated 2011 and Hepatitis B status for the practice manager only. The provider has since sent evidence they had applied for DBS certificates for all staff following the inspection.

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 always enough staff on duty. 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 did not have a system in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were some effective processes to support and develop staff with additional roles and responsibilities. Due to being part of a small team, staff discussed their learning needs, general wellbeing and aims for future professional development during one-to-one meetings and ongoing informal discussions. There were no records of performance reviews or appraisals to ensure learning and development needs were identified. The provider told us they would implement an appraisal system.

Staff felt respected, supported and valued, and they were proud to work in the practice.

The practice had infection control procedures, however, these did not always reflect published guidance.

We were not provided with evidence all staff had received appropriate training, and they did not demonstrate a robust knowledge and awareness of infection prevention and control processes.

Staff decontaminated dental instruments after use, we observed that this was not fully in line with national guidance. The staff member we observed did not use all the required personal protective equipment (apron and face mask), a pre-enzymatic spray/soak was not used to keep instruments moist to mitigate a delay in processing, instruments were not immersed or scrubbed under running water and a thermometer was not used to ensure the water temperature was below 45 degrees. We saw, and staff confirmed that single-use items were not reprocessed.

Record-keepingfor all key tasks and duties required to be completed within the decontamination room at the start of clinical sessions and the end of clinical sessions was not in place.

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 did not follow protocols to ensure the safe segregation and disposal of hazardous waste. We observed a clinical waste bag stored behind a curtain in the waiting room and clinical waste bags stored on the ground behind the clinical waste bin outside of the practice. The outside clinical waste bin was not tethered and could be removed by unauthorised people.

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

Although, staff completed infection prevention and control audits in line with current guidance, these did not identify any of the issues we highlighted during our inspection. Areas in the audit staff identified as being non-compliant did not have an action plan to mitigate the risk.

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