Castle Street 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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

Whilst 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 practice should improve its safeguarding procedures and ensure all staff have received the appropriate level of safeguarding children and vulnerable adults training at the required intervals. The practice did not have safeguarding processes and staff were unaware of their responsibilities for safeguarding vulnerable adults and children. The safeguarding policy available was newly implemented and not embedded.

The practice had safeguarding posters and flow charts displayed for staff to follow. However, these had not been updated for a number of years. We saw staff had not undertaken appropriate training in safeguarding vulnerable adults and children. The provider submitted an updated safeguarding policy in the days after the assessment and confirmed all outstanding training was completed on 19 February 2025.

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. Staff did not feel confident that risks were well managed at the practice, and this was reflected in our findings. The practice had not carried out a Health and Safety risk assessment to help them manage risks to staff and patients. Risks associated with sharps were not appropriately risk assessed or managed.

Emergency medical equipment was not managed effectively. Although the required emergency medicines were available, we found multiple medical equipment items missing or expired and the checklist in place was not carried out in line with national guidance. The items missing or expired included but were not limited to self-inflating bags with reservoirs for adults and for children, and clear face masks in all sizes. The provider took immediate action to mitigate the risk to safety and ordered all missing and expired items on the day of assessment. They also implemented a new checklist and confirmed the frequency of checks would be in line with guidance moving forward.

Staff had not completed regular training in emergency resuscitation and basic life support. Staff we spoke to were unable to demonstrate an awareness or describe how to deal with a medical emergency. We raised this with the provider who took immediate action and booked basic life support training for 20 February 2025. They did not have any patients booked for treatment until after staff received the training.

There was no bodily fluids kit, no blood spillage kit and no emergency eye wash kit available on the day. These were all ordered by the provider on the day of assessment.

There was no system or process to manage, identify or dispose of out-of-date stock or damaged equipment. The surgery drawers contained out-of-date materials, equipment and local anaesthetic cartridges. We also saw visible damage to the lining of the dental chair. All expired materials, equipment and local anaesthetic cartridges were disposed of on the day of assessment.

Hazardous substances were clearly labelled and stored safely. However, the practice had not carried out risk assessments in relation to the safe storage and handling of all the substances hazardous to health within the practice. We discussed this with the provider and were assured these would be completed within the next 4 weeks.

The X-ray unit was last serviced in 2007 and there were recommendations that had not been actioned by the provider. A service of the X-ray unit had been arranged but no evidence was sent following the assessment. The practice had not carried out radiography audits six-monthly following current guidance and legislation.

The management of fire safety was not always effective. The provider had sourced a fire risk assessment from an external company shortly prior to our assessment day. The provider had not received the fire risk assessment report, and it was not available to review on the day of assessment. We saw non-clinical rooms were cluttered and contained multiple combustible items. In addition, the provider was unable to provide evidence of an Electrical Installation Condition Report. However, fire exits were clear and well signposted.

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

Staff told us that there were sufficient levels of staff on duty at all times. Staff discussed their learning needs, general well-being and aims for future professional development during practice team meetings and ongoing informal discussions. Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

The practice did not have arrangements to ensure staff training was up-to-date and reviewed at the required intervals. The practice did not have systems in place to ensure clinical staff had completed Continued Professional Development (CPD) as required for their registration with the General Dental Council. In particular, medical emergencies and safeguarding training were not available on the day of the assessment for any member of staff.

The practice had infection control procedures that reflected published guidance. However, these were not always followed and we witnessed that manual cleaning of dental instruments were not being processed in line with best practice guidance. Staff were also not checking or recording the water temperature during manual cleaning and there was no weekly residual air test for the autoclave. The practice should improve their systems to maintain oversight of infection prevention and control to ensure staff are always following published guidance. We discussed these issues with the provider who took appropriate immediate action.

The practice had ineffective procedures to reduce the risk of Legionella or other bacteria developing in water systems. A Legionella risk assessment had been carried out on 7 February 2025, but recommendations had not been actioned. We saw staff had checked and recorded hot water temperatures since the risk assessment, but these were below the required temperature with no evidence of action taken to rectify. The temperature check log was not working effectively and was being completed incorrectly. There were also no records available to demonstrate that water testing and dental unit water line management were carried out prior to the Legionella risk assessment. The provider booked an external contractor to investigate the hot water system for 21 February 2025.

The practice completed infection prevention and control audits in line with current guidance. However, the last audit completed in October 2024, did not reflect protocols we witnessed on the assessment day.

We observed use of personal protective equipment. We saw, and staff confirmed that single use items were not reprocessed.

The practice’s protocols to ensure safe segregation and disposal of hazardous waste were not always working effectively. We saw that sharps bins and clinical waste were not always managed in line with the Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste. In particular, sharps bins were being filled above the fill line and were not labelled and clinical waste sacks were not being stored securely prior to collection.

The governance and oversight of environmental cleaning was not managed effectively. Staff completed environmental cleaning logs, and we saw that patient fronting clinical areas were visibly clean. However, we observed the communal and non-clinical areas of the practice to be cluttered and visibly unclean, including behind units within the surgery.

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