Crofton 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 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 safety of the premises and equipment, adequacy and availability of emergency equipment and medicines and the infection prevention and control standards not being followed at the practice

These concerns were in breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 have effective systems to identify, monitor and manage all risks. We noted that a fire risk assessment and a general health and safety risk assessment had been carried out by an external company in 2023 but there was a lack of evidence that all actions identified within the risk assessments had been addressed or reviewed at appropriate intervals.

Emergency medicines were generally available in line with national guidance. However, the practice did not have all of the emergency equipment recommended by national standards and checks of emergency medicines and equipment were not effective. We found some emergency equipment and medicines had expired, and some items needed to manage medical emergencies were not available. Staff were also unable to clearly explain the use of some emergency medicines and equipment. Following our inspection feedback, the practice took action to address some of the concerns. These findings indicated that systems for managing and checking emergency medicines and equipment were not effective.

We found that only one member of staff had completed accredited practical hands-on basic life support training. This meant there was insufficient assurance that all staff had the practical skills required to respond appropriately in the event of a medical emergency. In addition, the practice provided conscious sedation to patients. The staff involved in delivery of conscious sedation had not completed practical immediate life support training within the last 2 years, nor did they participate in medical emergency scenario training; this was not in line with published guidance. Staff told us they were not fully confident in managing medical emergencies and sedation-related complications and had requested additional practical training. However, they told us this training had not been made available. Following the inspection we have received evidence that hands-on Immediate Life Support training had been arranged for all members of staff on 10 August 2026.

While this demonstrated a commitment to improvement, at the time of the inspection there was insufficient assurance that the practice had enough suitably trained staff to respond effectively to a medical emergency.

The premises were visibly clean. We saw satisfactory records of servicing and validation of equipment, including the air receiver, dental chairs, suction motor and one autoclave in line with manufacturer’s instructions. However, improvement was required to ensure that the practice’s system for maintaining equipment and premises was effective.

There was evidence that portable electrical appliances were regularly tested and maintained. The provider also supplied evidence that the premises had recently undergone maintenance. However, we were not assured that premises maintenance had previously been carried out consistently or in accordance with recommended timescales. For example, gas safety checks had not been undertaken consistently on an annual basis as required. Staff had identified within risk assessments that an Electrical Installation Condition Report (EICR) was required and had raised this with the provider. Despite this, the EICR was not completed until June 2026.In addition, the fixed air conditioning system had not been serviced by a competent person in accordance with the manufacturer’s instructions. This increased the risk that faults or safety issues, including potential fire hazards, may not be identified promptly.

Hazardous substances were clearly labelled and stored safely.

The practice did not have adequate arrangements to ensure the safety of the X-ray equipment and not all the required radiation protection information was available. On the day of inspection, staff were unable to readily access the practice’s safety procedures and when they were located, we were not assured that they could be followed in practice. In particular, the operator should close the room door and stand outside the room during exposures, whilst ensuring that the patient could be observed at all times. However, the room door could not be closed when the equipment was in use. Staff told us that a camera and monitor had previously been available to observe patients remotely, but this system had been out of service for some time. As a result, staff explained that the only way to observe patients during exposures was to leave the door partially open while operating the equipment.

These findings indicated that effective systems were not in place to support the safe use of X-ray equipment or ensure compliance with radiation safety requirements.

Furthermore, the provider had been advised of concerns by their Radiation Protection Advisor (RPA) following a routine performance test in May 2021. The RPA highlighted that the arrangements in place did not align with the Local Rules and recommended that the pre-installation radiation protection assessment be reviewed. Advice was also given to improve signage to help keep people away from nearby areas during X-ray exposures.

Despite these recommendations having been made several years earlier, we did not see evidence that all required actions had been implemented. This indicated that identified radiation safety concerns had not been addressed in a timely manner.

In addition, evidence seen during the inspection indicated that the CBCT equipment had been installed in approximately 2016. However, the Critical Examination and Acceptance Test, which should be completed before equipment is brought into clinical use, were not carried out until 2020. This meant the provider could not demonstrate that the equipment had undergone all required safety checks and verification before being used to expose patients to ionising radiation.

There was insufficient evidence to demonstrate that all X-Ray equipment was tested or maintained at intervals as recommended by the RPA. Following our feedback, we received assurance that the X-Ray equipment tests and services had been arranged.

Staff told us that the X-ray equipment in surgery 3 was not used and had been disconnected and therefore there was no requirement to maintain it. However, on the day of inspection, we observed the equipment had been switched on at the mains and appeared to be in a state of readiness.

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.

The practice had implemented some measures to reduce the risk of fire. A fire risk assessment had been completed by a competent person in March 2023 and identified a number of actions to improve fire safety. We found that the provider had taken steps to address several of the recommendations; However, the provider had not implemented all of the actions identified within the assessment or demonstrated that they had assessed the risks associated with the outstanding actions. In particular, a fire alarm system had not been installed and fire drills were not being conducted. Regular fire drills are important to ensure staff understand how to respond effectively in the event of a fire emergency and to test the effectiveness of evacuation arrangements.

Although the provider informed us that arrangements had been made for a new fire risk assessment to be undertaken and for a contractor to install a fire alarm system, they were unable to provide sufficient evidence to substantiate this when requested following the inspection.

During our inspection, we also observed considerable clutter within the roof space, an area subject to elevated temperatures. In addition, there was no evidence that the fire risk assessment was subject to regular in-house review to ensure that identified risks remained appropriately managed and that outstanding actions were monitored to completion. As a result, we could not be assured that effective arrangements were in place to manage fire safety risks.

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

The practice had a recruitment policy and procedures that reflected relevant legislation, however these were not followed consistently. We reviewed personnel records and found that satisfactory evidence of conduct in previous employment relating to health and social care services, or work with children or vulnerable adults, was not available for any relevant members of staff. In addition, evidence to demonstrate that the provider had undertaken appropriate proof of the right to work in the UK checks was not available for all members of staff. The practice manager responded during the inspection and obtained the required evidence to confirm the individual’s right to work in the UK.

The provider's disclosure policy, reviewed in 2024, stated that all new members of staff would undergo a Disclosure and Barring Service (DBS) check. However, we found that four members of staff who had joined the practice did not have a DBS check obtained by the provider in accordance with the policy.

We saw that risk assessments to mitigate the risks associated with the absence of these DBS checks had been completed. However, these assessments had only been undertaken shortly before the inspection and there was no evidence they had been completed at the time the staff members commenced employment. This meant the provider could not demonstrate that risks had been appropriately considered and managed throughout the period of employment.

In addition, two members of clinical staff had only received basic DBS checks. The provider was unable to demonstrate that it had assessed whether the level of check obtained was appropriate for the duties undertaken by those staff members.

Health assessments for newly appointed staff were not conducted to ascertain information about any physical or mental health conditions which were relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity. There was evidence that vaccinations against Hepatitis B had taken place for all clinical staff, however, proof of immunity was unavailable for 2 of these.

As a result, we could not be assured that appropriate systems were in place to ensure staff were suitable for their roles.

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

There was evidence to demonstrate that newly appointed staff had undergone induction processes.

Staff told us that there were enough staff on duty at all times. 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 ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals with the exception of practical life support training.

There were some 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 and practice team meetings and ongoing informal discussions. Staff told us that suggestions for training were not always considered.

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

There were processes in place, however improvements were required to ensure items including radiographic holders, burs and matrix bands are pouched after sterilisation to minimise the risk of contamination. We also found that the temperature of the water used for manual scrubbing of instruments was not being monitored. This meant the provider could not demonstrate that the process was being carried out under conditions consistent with recommended decontamination procedures.

Furthermore, the illuminated magnifier used to inspect instruments for residual debris and defects was not connected to the mains power supply at the time of inspection. As a result, illumination was unavailable and staff could not demonstrate that instruments could be effectively examined to ensure they were visibly clean and suitable for use on patients.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. However, we identified concerns regarding the accuracy and reliability of surgery checklists. Records reviewed during the inspection indicated that some checklists had not been completed contemporaneously or did not accurately reflect the activities taking place within the surgeries. The end-of-day checklist for Surgery 2 had been completed during the early afternoon, before the final patients of the day had been seen. We also noted inaccuracies within the Surgery 3 set-up checklist. The checklist recorded that the impression bath had been set up and was available for use. However, the surgery was being used by the hygienist, who confirmed they did not undertake impression-taking procedures. These findings suggested that surgery checklists were being completed as a routine administrative exercise rather than being used as an effective safety tool. As a result, the practice could not be assured that essential opening and closing checks were being carried out consistently or that records accurately reflected the status of the clinical environment.

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

Equipment was maintained and serviced in accordance with manufacturers' instructions. The practice had also considered business continuity arrangements by retaining a spare autoclave to support continued decontamination processes in the event of a breakdown of the primary autoclave. The provider should ensure that the contingent autoclave is subject to appropriate checks, servicing and maintenance so that it remains safe and ready for use when required.

Improvements were required to ensure effective sterilisation processes were in place. We found that the practice was unable to demonstrate that its main sterilisation equipment was operating effectively. Records were not consistently completed, and checks designed to confirm the equipment was achieving the required sterilisation standards were not adequately monitored or documented. As a result, the provider could not demonstrate that instruments were being sterilised consistently and effectively before use.

On the day of inspection, we identified concerns regarding the validation and ongoing monitoring of the ultrasonic cleaning process. Staff were unable to provide a consistent or reliable account of the quality assurance measures in place to ensure the ultrasonic bath was operating effectively. At our request, a soil test was carried out during the inspection, The test failed, indicating that the ultrasonic cleaning process may not have been operating effectively.

The findings meant the service could not provide assurance that the ultrasonic cleaning equipment was being effectively monitored, validated and maintained in accordance with relevant decontamination guidance. Following our feedback, the provider assured us that a new ultrasonic bath would be purchased.

The practice did not routinely complete infection prevention and control audits at 6 monthly intervals in line with current guidance. The audit carried out in July 2026 contained inaccuracies and therefore had not identified where improvement were required. For example, the audit entries referred to washer disinfector and vacuum autoclave equipment, neither of which were available at the practice. In addition, the findings indicated that the temperature of water for manual scrubbing was measured and that instruments were inspected under an illuminated magnifier. These statements were not reflected in the findings on inspection. We also reviewed the digital audit record and noted that it was time-stamped in a manner that indicated the audit had been completed within a matter of seconds. This raised concerns that the audit had not been undertaken in a sufficiently thorough manner and demonstrated a lack of attention to detail.

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