Woodhall Dental Practice Limited

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 and equipment.

These concerns were in breach of Regulation 12 Safe care and treatment

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.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, however this was not always reflected in our findings.

The practice did not have effective process for the identification and management of all risks relating to the provision of regulated activities at the practice. We identified concerns with the assessment and management of risks associated with fire and electrical safety, waste, medical emergencies, Legionella, servicing and maintenance of equipment and the control of substances hazardous to health (COSHH).

Improvements were required to ensure that all medical emergency drugs and equipment were available to staff and checked in line with national guidance. We saw that portable suction and a spacer device for the administration of the medicine Salbutamol were not present on the day of the inspection and there was only one size of the self-inflating bag with reservoir which was undated and not stored appropriately. Weekly checks were carried out for the emergency medicines, but these did not include the oxygen cylinder, automated external defibrillator or other emergency equipment. The medicine used to manage low blood sugar (Glucagon) was stored at room temperature, however, the expiry date had not been adjusted in accordance with the manufacturers’ guidance. Following the inspection, the provider ordered all missing and out of date emergency equipment and the glucagon expiry date was corrected. We were provided with evidence that an effective weekly check of the emergency medical equipment was being implemented.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean and free from clutter. Hazardous substances were clearly labelled and stored safely. The provider had completed Control of Substances Hazardous to Health (COSHH) risk assessments and safety data sheets were available for some dental materials. Improvement was required to ensure that safety data sheets and risk assessments for all dental and general cleaning products in the practice has been completed. Immediately following the inspection, the provider obtained safety data sheets for the cleaning products used in the practice.

We were not provided with records of servicing and validation of the dental compressor and the air conditioning unit was last serviced in 2014. We saw that the air conditioning service was scheduled for 14 April 2026.

The practice did not have an up-to-date Electrical Installation Condition Report (EICR) to ensure the electrical system and wiring in the building was safe. The practice told us that this had been scheduled for 12 May 2026.

The practice had some arrangements to ensure the safety of the X-ray equipment and most of the required radiation protection information was available. However, we saw that the annual electromechanical service of the X-ray units had not been completed and the local rules were not reviewed or dated. 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 could not demonstrate that a comprehensive fire safety risk assessment had been undertaken by a trained and competent individual. The smoke detection and emergency lighting systems had not been serviced and the practice was not completing periodic in-house checks. Staff had not completed verifiable fire awareness training, although inhouse training had been provided during induction and at a staff meeting. We saw that the fire extinguishers had been recently updated and that fire exits were clear and unobstructed. Immediately after the inspection, the provider shared evidence that an external fire risk assessment was completed on 4 April 2026 and servicing of the fire alarm and fire training for staff had been arranged for 27 April 2026.

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 had a recruitment policy and procedures that mostly reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. Improvements could be made to ensure the provider checked all information in respect of persons employed or appointed for the purposes of a regulated activity as set out in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some staff records did not include evidence of satisfactory conduct in previous employment, or evidence to show the effectiveness of vaccination for Hepatitis B. We were told this would be rectified.

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 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. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice had some processes to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Improvements could be made to ensure that all staff received training appropriate to their role with regards to safeguarding for children and vulnerable adults and fire awareness training. We were told by the provider that fire awareness training had been arranged for 27 April 2026.

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, one-to-one meetings, practice team meetings and ongoing informal discussions.

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

The practice had infection control procedures that mostly 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 were told that unpouched dental instruments that were stored in the treatment rooms were sterilised at the end of the day. However, there was no written protocol to demonstrate this and we saw some unpouched matrix bands in an out of use surgery on the day of the inspection. Staff confirmed that single-use items were not reprocessed.

An external Legionella risk assessment had been completed the week before the inspection however, the recommended measures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line current guidance had not been implemented. The practice was not recording the hot and cold water temperatures despite this being a recommended action from the previous risk assessment completed in 2016. Immediately following the inspection, water temperature logs were implemented.

The practice had protocols to ensure effective cleaning of the practice. Improvements were required for the storage of clinical waste, on the day of the inspection we saw that the clinical waste container could not be locked and was not secured to a fixed structure.

Decontamination equipment was maintained and serviced in line with 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.