Dental Surgery

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 line with the relevant regulations and had taken into consideration appropriate guidance.

Although there are issues to be addressed, the impact of our concerns relates to the governance and 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 had processes to identify and manage some risks. We identified concerns with the risk assessments for and management of fire safety, electrical safety, prescription management, sharps safety and the control of substances hazardous to health (COSHH).

A fire risk assessment had been completed in January 2025 which identified required actions. We saw that some actions were still outstanding, which were of both high and medium priority. Following this feedback, we were told that actions were due to be completed and documented.

The practice had not ensured that the facilities were maintained in accordance with regulations, as an Electrical Installation Condition Report (EICR) which ensures the electrical system and wiring in the building was safe, was carried out in June 2025 and was unsatisfactory. At the time of this inspection, no remedial actions had been completed, and we were told that this work was planned for April 2026. Following feedback that the practice should ensure the suitability of the premises, we saw that the work was due to be completed imminently.

We were told that the boiler had not been functional for 2 years; no hot water was available for staff or patients. The practice should take action to ensure both hot and cold running water is available in areas where employees are expected to wash their hands taking into account the Workplace (Health, Safety and Welfare) Regulations, 1992. Following this feedback, we saw that arrangements had been made for a new boiler to be installed.

Whilst a sharps risk assessment had been completed, it was not reflective of the processes in place. Following this feedback, the practice told us they had reviewed the use of sharps, and the risk assessment had been updated.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Hazardous substances were clearly labelled and stored safely. However, the COSHH folder was incomplete, and not all risk assessments were present. Additionally, no manufacturer safety data sheets (SDS) were available. Following this feedback, the practice told us these would be completed and COSHH management would be improved in accordance with the Control of Substances Hazardous to Health Regulations 2002.

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. This included cone-beam computed tomography (CBCT). However, improvements were required to ensure that any actions arising from radiation reports were completed. 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.

NHS and private prescription pads were kept securely, yet no system was in place to track their usage and therefore the practice would not be able to identify if a prescription was missing. Following this feedback, we were told that a log will be implemented.

Whilst these issues were present, our concerns relate to lack of governance and risk oversight, rather than immediate patient and staff safety.
 

The practice had a recruitment policy, however the practice procedures in place did not reflect the policy or relevant legislation, as on the day of our inspection, we were not shown satisfactory recruitment evidence for all staff. There was no evidence that staff had adequate immunity to Hepatitis B. Following this feedback, we were told that staff had been asked to obtain this evidence of immunity and some recruitment checks were completed.

Newly appointed staff had an appropriate role specific structured induction.

Staff had skills and knowledge to carry out their roles. Staff demonstrated some knowledge of safeguarding.

The practice did not have the oversight to ensure that staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. Following this feedback, the practice told us these will be implemented.

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

The practice had infection control procedures that generally reflected published guidance. The premises were visibly clean, although there was significant clutter in the treatment rooms. Additionally, we saw that items such as tissues were uncovered on the surfaces and open to aerosol contamination. Improvements should be made to ensure that the practice’s infection control procedures and protocols took into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices. Following this feedback, the practice told us that these open items and clutter had been removed.

Staff received some training and demonstrated some knowledge and awareness of infection prevention and control processes.

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.

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 have protocols to ensure effective cleaning as no cleaning schedules were available for use. Following this feedback, we were told that these would be implemented.

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

The practice completed infection prevention and control audits in line with current guidance.
 

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