Clover House 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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

The provider had made improvements in relation to the regulatory breaches we found at our inspection on 3 February 2026.

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.

Environmental risks posed by the building had been addressed. Fire safety officers had visited and surveyed the building, and assessed what steps were needed to make it safe. All recommendations had been acted on, and required changes to the building had been completed. Staff with lead responsibility for fire safety had been given sufficient training to equip them for this responsibility.

Changes to medicines management had been made. We had previously seen that the system in place did not allow staff to balance stocks of medicines held, and account fully for medicines dispensed and by whom. A new system had been introduced that limited which staff could prescribe and dispense medicines but allowed all clinicians to prescribe medicines required. Patients would then take the prescription to the pharmacy for fulfilment. This new system appeared to be working well.

At our inspection of 3 February 2026 we identified that some staff did not have the knowledge required to ensure all legally required registrations, for example, registration of the practice with MHRA and for the custom-made devices being produced at the onsite laboratory. This had been addressed and we saw evidence of registration of the practice and the devices it produces. We drew the attention of the practice manager to the lack of recent training and development for the dental nurse producing teeth whitening trays. We confirmed with the provider the General Dental Council (GDC) continuing professional development (CPD) requirements for dental nurses and prompted the provider to source any required training.

The provider should implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.

At our inspection of 3 February 2026, we found a lack of evidence of routine testing, linked to work in the decontamination room, and confusion about who was responsible for keeping records of efficacy tests. At our follow-up inspection, we found this had been addressed. A designated person was now appointed to carry out this work and to maintain logs and records as required. We found that all efficacy testing was recorded and uploaded to the practice computerised compliance system, which meant this could be overseen by the practice manager. We also confirmed that deputising arrangements were in place so this work would continue during any period of absence of relevant staff members.

Staff had also received updated training on control of Legionella in dental practices. At our previous inspection, we saw records of water temperature testing, where the hot water temperature was consistently below 50 degrees centigrade, and this had not been brought to the attention of the practice manager. This indicated that staff carrying out this testing did not understand the importance of the required temperature range for hot and cold water used in the practice. This had been addressed and records now showed that hot and cold water temperatures were within the range required for control of Legionella in water systems.

At our last inspection, the practice was not able to show us an antibiotic audit. We did see radiograph and patient record audits.

At our follow up inspection of 22 May 2026, we were shown recent antibiotic audits. There was no reference to the protocol being audited against, no summary of findings or evidence of discussion with the clinicians concerned. We have identified that this is an area for further improvement.

The provider should implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the College of General Dentistry.

Our findings from this inspection demonstrated that the provider is now compliant with Regulation 15 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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