Southbrook Dental Practice

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led care in accordance with the relevant regulations.

The provider made insufficient improvements to address the shortfalls and regulatory breaches we found at our inspections on 20 November 2024 and 3 July 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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 Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

At the inspection on 25 March 2026, we found the practice had made minimal improvements towards being compliant with the regulations.

The practice staff demonstrated an honest attitude towards the inspection process and were open to discussion and feedback, and the issues identified.

The provider had engaged the services of an external compliance consultant to support them to make the necessary improvements. A detailed action plan had been developed by the provider and was sent to us in August 2025. However, we found the majority of this had not been actioned.

Effective systems and processes had not been established to ensure the risks associated with the carrying on of the regulated activities were appropriately managed. In particular, risk assessments for health and safety, and hazardous substances were yet to be completed. A sharps risk assessment was now in place and staff understood and followed the procedures to reduce the risk of sharps injuries.

The recruitment policy was in place and reflected current legislation. However, this was not being followed. There were inconsistencies in obtaining evidence of photographic identification, satisfactory response to Hepatitis B vaccinations, carrying out Disclosure and Barring Service (DBS) checks at the point of employment.

The practice did not have effective processes to support and develop staff and ensure their training was up-to-date. We saw induction checklists for new staff. However, these were only partially completed.

We looked at 25 patient care records. The information recorded in these patient care records was not in line with current recognised guidance. Dental care records did not include sufficient evidence of the examination and consent process, with limited evidence of periodontal assessments, diagnosis and oral health advice provided to patients. We discussed this with the dentist and signposted them to nationally agreed guidance to support them. We were assured it would be addressed and rectified. The justification of antimicrobials prescriptions should be reviewed and improved.

There was insufficient oversight of infection prevention and control procedures.

Audits had been carried out for radiography, antimicrobial prescribing and dental care records in the days prior to our visit. These highlighted issues in line with our inspection findings. The provider confirmed that changes were being planned, but these had not yet been implemented at the time of the inspection.

Improvements were required to the system for identifying and managing the risk associated with the carrying out of the regulated activities.

A fire risk assessment had been carried out on 26 June 2025 in line with legal requirements. The report included recommendations which had been highlighted at our previous inspection and the practice fire policy stated any actions arising from the fire risk assessment are addressed in accordance with assigned timeframes.

However, the recommendations had not been actioned effectively. A fire alarm test procedure had been established, we saw staff participated in a fire drill in January 2026, and had begun carrying out checks of fire detectors and extinguishers, but log sheets showed, and the provider confirmed these checks ceased again in January 2026. An action to provide emergency lighting in stairwells had not been actioned, torches were available but not in the appropriate locations and the recommended electrical appliance testing had not been carried out.

We saw satisfactory records of servicing of equipment in line with manufacturer’s instructions. We had previously highlighted the provider should ensure that staff carry out appropriate validation checks of the sterilisers. This had not been actioned.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. Infrequently used outlets were now flushed on a regular basis. Hot water temperatures were being recorded inconsistently and cold-water temperatures were not checked. In addition, we saw a jug used to collect purified water for use in the sterilisers and dental unit waterlines contained visible biofilm. Biofilm is a layer of microbes that grows on and sticks to a surface if not regularly cleaned. The staff member who carried out Legionella checks had not completed Legionella awareness training as recommended by the risk assessment.

We observed use of personal protective equipment and the decontamination of used dental instruments, which broadly aligned with national guidance. We saw, and staff confirmed that single use items were not reprocessed. The inspection highlighted areas for improvement. In particular, ensuring heavy duty gloves are changed regularly, immersion of instruments in water or appropriate detergent when there are delays to reprocessing, monitoring the temperature of manual cleaning solution and the validation of equipment.

Emergency medicines and equipment were available as specified in Resuscitation UK Guidance. Staff received appropriate training to respond to medical emergencies.

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

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.