Gareth Roberts - 69 Pont Street

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 the safety of the premises and the infection prevention and control standards not being followed at the practice.

These concerns were in breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) 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 processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice, and this was reflected in our findings.

On the day of assessment, midazolam oramucosal solution, a medicine used to treat prolonged seizures, was not available in accordance with national guidance. Following feedback, the practice sent evidence that this had been purchased.

Staff providing treatment to patients under sedation had not completed immediate life support training, or basic life support training supplemented with patient assessment, airway management techniques, and automated external defibrillator training. This training had expired on 12 March 2025. The practice told us they would not continue to offer sedation until staff had received the appropriate training. Following the inspection, we received evidence that the appropriate training had since been completed.

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. This practice had a cone-beam computed tomography machine (CBCT). This was out of use on the day of our inspection.

A fire risk assessment was carried out in line with legal requirements. This had not identified risks in relation to evacuation of patients under sedation. The management of fire safety was not always effective. There were insufficient systems in place to ensure the fire alarm, emergency lighting, and fire extinguishers were regularly checked and maintained. Additionally, there was no evidence of routine fire evacuation drills being carried out.

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

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff.

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 we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times.

The practice had some arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, improvements were needed to ensure all staff had completed training in how to interact appropriately with autistic people and people who have a learning disability. Additionally, staff who conducted CBCT scans had received appropriate training.

Although staff had completed training in safeguarding and sepsis, not all staff demonstrated confidence on how to deal with sepsis and safeguarding concerns. The practice demonstrated a commitment to deliver refresher training which would be regularly reviewed.

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 and ongoing informal discussions.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

The practice had infection control procedures that reflected published guidance. However, these were not reflective of processes in place. We observed the decontamination of used dental instruments, which did not fully align with national guidance. Staff scrubbed instruments under running water and there were no systems to ensure the temperature of water used for cleaning was 45C or under, as required. In addition, the detergent used for manual cleaning was not measured to ensure the correct dilution was achieved in line with manufacturer`s guidance. Improvements were required to ensure the dirty and clean areas were adhered to during the decontamination process. There was also no system to ensure that the heavy-duty gloves were being changed weekly.

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.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

The equipment in use was maintained and serviced as per 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.