Dental Surgery - Main Street Billinge Also known as Saxon Dental Care

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.

Whilst there are issues to be addressed, the impact of our concerns relate 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.

The practice identified and managed risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working. We noted that the health and safety and sharps risk assessments did not reflect our findings on the day. We discussed this with the provider, and they booked an external health and risk assessment for 31 March 2026.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and this was reflected in our findings.

We noted that checks on emergency equipment and medicines were not done in accordance with national guidance, as a result, some equipment was missing. All missing equipment was ordered during the inspection, and a new weekly medical emergency kit checklist was created during the inspection.

They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean, well maintained and free from clutter.

Hazardous substances were clearly labelled and stored safely. However, the practice had not carried out risk assessments in relation to the safe storage and handling of all the substances hazardous to health within the last 12 months, people working at the practice also had limited access to the relevant safety data sheets. We discussed this with the provider and were assured these would be completed within the next 4 weeks.

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

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

Improvements were required to the oversight and management of fire safety. We saw no evidence that a fire risk assessment had been carried out by a competent person. As a result, smoke alarm tests and fire extinguisher visual checks were not carried out in line with guidance. The provider acted immediately and booked an external fire risk assessment for 31 March 2026.

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

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times.

Staff 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. However, they were unclear of their responsibilities regarding the oversight of Was Not Brought within the practice. Was Not Brought is a code for when a child or an adult, who is reliant on another person to get an appointment, has missed their appointment. Missed appointments can be a sign of neglect and therefore providers should have appropriate safeguarding systems and processes to monitor and have oversight of missed appointments, particularly for children and vulnerable adults.

We noted the safeguarding policy was generic and did not identify lead roles or specify local arrangements for safeguarding.The provider updated the safeguarding policy and safeguarding flowcharts on the same day as the inspection with details of the safeguarding lead and relevant local authorities.

The practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, oversight of staff training was not always effective. On the day of the assessment, we saw gaps in training completed for 1 member of staff. All outstanding training was completed on the inspection day.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, one-to-one meetings, during clinical supervision and practice team meetings and ongoing informal discussions.

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

The practice had infection control procedures that reflected published guidance. Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

We noted that foil tests, which test the efficiency and distribution of cavitation in an ultrasonic cleaner, were not completed in line with guidance. We discussed this with the provider and were assured these would be carried out in line with guidance from now on.

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

Improvements were required to the oversight and management of Legionella. We saw no evidence that a Legionella risk assessment had been carried out by a competent person, as a result, hot and cold-water temperature checks were not carried out in line with guidance. The provider acted immediately and booked an external Legionella risk assessment for 31 March 2026.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions. The practice completed infection prevention and control audits, however they were not always completed in line with current guidance as they were completed annually. We discussed this with the provider and were assured they would be completed every 6 months in the future.

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