James Spence 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 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 management of risks required improvement. This included fire safety, control of Legionella, and the ongoing maintenance of equipment and premises.

A suitable and sufficient health and safety risk assessment had not been carried out for the dental practice. Without a risk assessment, hazards may go unidentified and unmanaged.

The practice’s health and safety policy stated that “compressors and autoclaves are regularly inspected and certified.” While records demonstrated that some equipment had been appropriately serviced and validated in accordance with manufacturer instructions, this was not fully consistent with legislative requirements. The compressor and autoclaves underwent mandatory pressure vessel inspections on the day of inspection. However, records showed that prior to this, the equipment had not been inspected since 2020 in accordance with their Written Schemes of Examination, as required under the Pressure Systems Safety Regulations 2000. This represents a period of non-compliance, during which statutory examinations were not carried out to confirm that the systems were safe to operate.

In mitigation, records confirmed that the pressure vessels had undergone servicing in 2025. However, routine servicing does not replace the requirement for formal examinations under a Written Scheme and therefore does not fully mitigate the risk.

There was evidence that the gas boiler and portable electrical appliances (PAT) were maintained and checked on a regular basis, demonstrating partial compliance with maintenance requirements. However, the Electrical Installation Condition Report (EICR), which is required at intervals not exceeding five years, had only been completed shortly prior to the inspection. Records indicated that the previous EICR had been undertaken in 2012, representing a significant lapse in compliance and a prolonged period without formal verification of the safety of the fixed electrical system. In addition, the air-conditioning system had not been maintained in accordance with the manufacturer’s instructions since 2020, meaning routine servicing requirements had not been met. Undetected faults or clogged filters can pose a fire fisk.

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.

The premises were visibly clean. Hazardous substances were clearly labelled and stored safely.

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

Improvements were required in the management of fire safety. We observed that fire exits were kept clear and unobstructed. Fire extinguishers were maintained by a fire service company and records demonstrated that the 2 battery-operated smoke alarms were tested on a weekly basis. However, the fire risk assessment, completed only days before our inspection, had been carried out by a person who we were not assured had the required training or competence to do so. Emergency lighting had not been maintained by a competent person and there was no evidence of regular in-house testing of the system. Fire drills were not carried out at appropriate intervals.

Following our inspection, the provider was responsive and promptly arranged a fire risk assessment which was carried out by a competent person on 27 April 2026 who identified 33 control measures to comply with Regulatory Reform (Fire Safety) Order 2005. Many recommendations related to insufficient signage and management, but key findings were the inadequate provision of fire extinguishers and lack of fire detection equipment. There was considerable clutter in a disused treatment room.

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.

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

Staff had some skills and experience to carry out their roles. They told us that there were enough staff on duty at all times. Improvements were required to ensure staff had the appropriate knowledge in core subjects.

The practice had not ensured that staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Improved oversight was required to ensure all mandatory training requirements were consistently monitored and completed. There was insufficient oversight of training compliance across the workforce. The provider had not ensured that all self-employed staff had completed required training, including practical Basic Life Support (BLS). Additionally, most staff had not completed training in autism and learning disability awareness training as required by the Health and Care Act 2022. Following our inspection, all staff completed the required autism and learning disability awareness training, and we received evidence that the self-employed staff had arranged and undertaken practical BLS training.

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.

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 procedures in place to reduce the risk of Legionella, or other harmful bacteria, developing in the water systems. A Legionella risk assessment was made available for our review; however, we were not assured this had been completed by a person with the necessary training and competency. The assessment lacked sufficient detail, as it did not fully consider the design, condition, or configuration of the water systems within the premises. Furthermore, there was no formal Written Scheme of Control in place, as required to effectively manage and monitor risks.

The Legionella logbook had not been consistently completed prior to 2026, indicating that routine monitoring and control measures had not been reliably implemented or recorded.

In response to our feedback, the provider acted promptly and a Legionella risk assessment was carried out by a competent person on 27 April 2026. They did not identify immediate safety concerns, however they highlighted some issues relating to management and governance which required improvement to achieve compliance with the Health and Safety Executive’s guidance: “Legionnaires’ disease. The control of legionella bacteria in water systems: Approved Code of Practice L8”.

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

The practice had not completed infection prevention and control (IPC) audits in line with current guidance. Although an IPC audit had been carried out shortly prior to our inspection, the previous audit had been completed in 2019, rather than at the recommended 6-monthly intervals as set out in Health Technical Memorandum 01-05: Decontamination in Primary Dental practices (HTM 01-05) published by the Department of Health. Lack of regular audits may limit the practice’s ability to identify and address any shortfalls.

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