Hangleton 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 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, staff recruitment, and training, support and development of staff including understanding, knowledge and awareness of safeguarding. We also found concerns related to infection prevention and control standards being followed at the practice.

These concerns resulted in breaches of regulations 12 Safe Care and Treatment, 18 Staffing and 19 Fit and proper persons employed 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 had ineffective processes to identify and manage risks.

A fire safety risk assessment had been carried out in December 2024 by an external company. We saw recommendations within this had not all been actioned, including installing a different fire detection system and relocating fire extinguishers. Fire evacuation drills had not been completed since May 2024 and not all staff had completed fire safety training. We also observed the fire door to the decontamination room was propped open with a chair. Following inspection, the provider told us they had arranged for a contractor to complete the required work to improve fire safety and took immediate action to ensure all fire doors remain closed. We found however, that the management of fire safety was not effective as the provider had not taken timely and appropriate action to mitigate the risks previously identified.

Staff could access emergency equipment and medicines that were checked in line with national guidance. We found an item of the medical emergency kit was missing. In response to our inspection feedback, the provider immediately purchased this following our inspection. They also sent evidence that all staff had completed training in emergency resuscitation and basic life support within the last 12 months. We found however that staff had not participated in medical emergency scenario training as recommended by the Resuscitation Council (UK) guidelines.

Overall, the premises were visibly clean, with the exception of the decontamination room. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, we found the daily testing of the autoclaves was recorded inconsistently.

The practice had arrangements to ensure the safety of the X-ray equipment. However, not all the required radiation protection information was available on the day of inspection. The provider submitted this after inspection. Improvements could be made to ensure paperwork related to radiation safety is easily accessible. 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 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’s recruitment policy and procedures did not reflect relevant legislation, to help them employ suitable staff, including agency or locum staff. Furthermore, documentation as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was not always available. For example, not all clinical staff had evidence of immunity to Hepatitis B. There was also missing DBS checks and/or risk assessments in staff records on the day of inspection. One member of staff did not have the appropriate level of enhanced DBS check, for working with both adults and children. In addition, satisfactory evidence of conduct in previous employment and a health declaration had not always been obtained. Although the provider sent some recruitment documentation following our inspection, this did not evidence that all required checks had been completed for all staff.

Newly appointed staff did not always have an appropriate role specific structured induction. Although there were computer based systems in place to ensure staff training was up-to-date and reviewed at the required intervals, these were not used effectively. For example, the overall training record showed that 4 clinical staff had not completed any training. For other staff, we did not see evidence of training in core areas relevant to dentistry. This included but not limited to evidence of training in infection control, fire safety and radiography.

The practice did not ensure that all staff completed safeguarding training to the appropriate level or updated their training at appropriate intervals. Not all staff had completed an appropriate level of safeguarding training for their role and some staff we spoke with could not demonstrate knowledge of how to respond to a safeguarding concern.

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

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 practice team meetings and ongoing informal discussions. However, improvements could be made to ensure processes to support and develop staff with additional roles and responsibilities were in place and embedded within the practice team. Not all staff had received 1 to 1 meetings or appraisals to support development.

The practice had infection control procedures that reflected published guidance but these were not always followed. We saw dirty surfaces, debris and limescale covered taps in the decontamination room. Staff did not wear appropriate personal protective equipment (PPE) and were unable to demonstrate satisfactory knowledge of the decontamination process in line with national guidance. We observed dental instruments left on worksurfaces and a box for dirty instruments placed on a general waste bin. A sharps box, in use, was seen in the room and a light magnifier for inspecting instruments was broken. The thermometer used for checking and monitoring the temperature of the enzymatic detergent used for manual scrubbing of instruments had no battery and was not in use. The provider took immediate action following the inspection and sent evidence the room had been deep cleaned. They confirmed that all instruments had been reprocessed and had addressed the faulty equipment.

We saw, and staff confirmed that single-use items were not reprocessed.

The practice completed IPC audits, but these were not reflective of practice or in line with current guidance. The most recent audit was completed in December 2024 with the next one planned for September 2025. This exceeds the recommended timeframe of 6 months.

Some of the staff were aware of infection prevention and control processes but had not received appropriate training and could not demonstrate knowledge of these. We were not assured that there was a well-developed and effective routine in place for environmental and surface cleaning, as the decontamination room was visibly unclean and decontamination and surgery checklists had not been completed consistently. Information sent to us following the inspection did not provide assurance that the provider had identified the issues found during this inspection.

The practice did not have robust protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste in line with the guidance issued in the Health Technical Memorandum 07-01. Clinical waste had not always been disposed of appropriately and we saw 2 overflowing clinical waste bins in the rear car park. The provider took immediate action to address this and amended the frequency to weekly collection with the appointed contractor.

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.

Equipment was maintained and serviced in line with manufacturers’ instructions. In response to our inspection feedback, the provider ensured that autoclaves were tested in line with guidance.

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