Bupa Dental Care Withington

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.

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 systems in place to identify and manage risks, and staff described the processes in place. This included sharps safety, sepsis awareness and lone working. However, some risk management processes should be improved, particularly in relation to fire safety and Legionella monitoring.

Staff demonstrated an open culture in relation to people’s safety and generally felt confident that risks were well managed at the practice.

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, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

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.

The practice had systems in place to manage fire safety; however, we identified some areas where these needed to be strengthened. This included ensuring all fire doors closed fully, keeping the basement fire exit unbolted when the building was in use, reducing the cardboard waste in the basement, and ensuring routine testing and review of fire safety equipment was completed consistently.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures in place; however, these were not consistently followed. For example, records did not demonstrate that hepatitis B vaccinations and titre levels were consistently monitored, or that associated risks were appropriately considered.

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

Records did not consistently demonstrate that newly appointed staff had received an appropriate structured induction when they started at the practice. We saw records where induction had been completed at a later date, after the gap had been identified.

They demonstrated a clear understanding of safeguarding and knew how to access relevant information. Staff were also aware of their responsibilities in protecting vulnerable adults and children.

The practice should improve their systems to ensure staff training, including continuing professional development, is up to date and reviewed at the required intervals. We saw evidence that training records were poorly maintained, and there were gaps in key areas including IR(ME)R, mental capacity, sepsis awareness, disability and autism awareness and basic life support. The interim Practice Manager had worked hard in the period immediately before the inspection to obtain evidence of completed training. The systems in place could not provide the leadership team with sufficient assurance that employed and self-employed staff had received appropriate training, learning and development to enable them to carry out their duties effectively.

There were processes in place to support staffing arrangements, including the management of staffing levels and cover. Staff feedback was mixed, with some staff describing staffing as sufficient or improved, while others highlighted periods of short staffing, and the impact this could have on their workload and wellbeing. We discussed this feedback with the leadership team during the inspection.

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.

The practice had protocols in place for Legionella monitoring; however, these should be improved. Records of thermal control were not maintained consistently during 2025, and the sentinel outlets identified in the risk assessment did not match those being monitored.

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 in line with current guidance.

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