The Dental Practice

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.

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

The practice had some processes which identified and managed risks and staff described the processes. This included sharps safety and lone working. We identified shortfalls in relation to the management of risks associated with fire safety and radiation safety.

Staff could access emergency equipment and medicines that were checked in line with national guidance. We noted that the Glucagon, a medicine to treat low blood sugar was stored in a refrigerator that was not temperature monitored to ensure that the cold chain was maintained. Following our feedback, this was rectified, and a log to monitor the temperature was implemented. 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 well maintained. However, a shortage of storage space resulted in clutter including environmental cleaning equipment in some of the communal areas. Hazardous substances were clearly labelled but we noted some flammable substances were not stored as recommended within the fire risk assessment.

The practice had arrangements which required improvements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT). In particular, the CBCT equipment had not received any routine performance tests since installation in January 2023. CBCT equipment requires annual testing in the absence of monthly in-house quality assurance testing. In mitigation a performance test was booked for 26 November 2025. 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.

A fire risk assessment had been completed in 2019. Not all actions arising from this risk assessment had been planned or completed. In particular, all doors should be upgraded in accordance with British Standards, and when they were to be kept open, magnetic door holders should be fitted. Flammable products should be kept in locked cupboards, and the fire exit should be fitted with a thumb turn lock. Additionally emergency lighting and a fire alarm system had not been installed according to the risk assessment’s recommendations. The practice had just 2 smoke detectors which had been identified as unsuitable and insufficient. In-house fire risk assessment reviews had been completed but these were not carried out by a person who could not demonstrate their experience or competence to do so. Following this feedback, the practice told us that actions would be completed, and an external company had been booked in to carry out the recommendations and carry out a new fire risk assessment. On the day of inspection, it was difficult to open the fire exit door as it had appeared to have suffered from some expansion, and daisy-chained extension leads were noted.

In mitigation, staff had been trained in fire safety awareness, drills were carried out, and the smoke detectors were tested on a weekly basis, and the results were recorded. Electrical equipment and the fixed wiring installations were inspected regularly. Fire exits were signposted, and the provider had supplied torches to be used in an emergency.

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 their use. Improvements could be made to ensure the tracking of prescriptions was more robust to prevent fraudulent misuse as described in current guidance.

The practice had a recruitment policy and procedure to help them employ suitable staff though we noted that some improvements were required to ensure the policy was always adhered to. We saw that some recruitment checks had not been carried out in accordance with relevant legislation. Not all new staff had new Disclosure and Barring checks (DBS) at the point of employment and a risk assessment stated that the practice would accept a historical DBS check if it was less than 4 years old. Staff were unable to provide a rationale for this approach. In addition, on the day of inspection, there was a lack of satisfactory evidence of conduct in previous employment (references) for 4 members of staff and employment histories for 3. Although there was evidence that vaccinations against Hepatitis B had taken place for all clinical staff, proof of immunity was unavailable for 2 of these which was contrary to the practice’s health and safety risk assessment.

In mitigation, the provider had identified that a number of DBS checks were outstanding and had initiated the applications immediately prior to the inspection. Following feedback, the provider sent 2 of the missing employment histories and 2 references, although the latter appeared to have been written following our inspection feedback.

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

Newly appointed staff had an appropriate role specific structured induction.

Staff broadly had the skills, knowledge and experience to carry out their roles. They 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. However, the contact details of the local safeguarding teams were incorrect as the wrong local authority had been identified. Staff knew how to escalate safeguarding concerns within the practice.

The practice ensured that some 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 was completed. Prior to our inspection, we viewed a worksheet log of all staff training but this was largely incomplete. In particular, not all clinical staff, including the Legionella lead person had received Legionella awareness training. Not all staff had completed training in autism and learning disability awareness as required by the Health and Care Act 2022. Sepsis awareness training had not been completed by many staff. Following feedback, we received evidence of some, but not all outstanding training.

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, practice team meetings and ongoing informal discussions. Improvements were required to ensure staff knew how to raise concerns if they felt unable to do so internally, as the whistleblowing policy lacked guidance on how to contact external agencies.

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.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. However, we observed that hot water temperatures were not consistently reaching the threshold of 55 Celsius as specified, and the provider had not ensured the responsible person had sufficient knowledge and training. Following the inspection feedback, the Legionella lead within the practice carried out awareness training.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. We noted that the clinical waste bin, although locked, was vulnerable to vandalism or theft, due to its location near to night-time venues and student accommodation. The practice may wish to consider securing the bin to the premises.

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

The practice completed infection prevention and control audits in line with current guidance, however they did not accurately reflect practice processes and equipment. Some of the clinical waste bins were not foot-operated and the blinds within the treatment rooms were not easily cleanable. The audits had not identified these issues.

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