Hall Street Dental Care

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, adequacy and availability of emergency equipment and medicines, recruitment, and training, support and development of staff, and the infection prevention and control standards being followed at the practice.

These concerns were in breach of Regulation 15, Premises and equipment.

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 systems to identify and manage risks. In particular, the risks associated with sharps safety, stock control, premises and equipment, lone working, fire safety and medical emergencies.

We noted sharps safety and lone working risk assessments had not been conducted.

Improvements were required to the systems for management and oversight of medical emergency equipment and medicines. On the day of inspection, we noted multiple items missing or expired and staff had not completed practical training in emergency resuscitation and basic life support. The provider acted immediately and submitted evidence that all items had been ordered within 24 hours following the inspection and evidence they had booked an emergency resuscitation and basic life support course for 19 February 2026.

Improvements were required to the oversight and governance of equipment and premises. We noted there was no evidence the premises had undergone a 5-yearly electrical installation condition report (EICR), there was no evidence of a gas safety certificate for the premises and portable appliance electrical testing had not been carried out. The practice submitted evidence following the inspection that the gas safety and portable appliance electrical testing had been booked in the near future.

The practice had some arrangements to ensure the safety of the X-ray equipment and some of the required radiation protection information was available. We noted the X-ray equipment had not undergone their annual electromechanical service and there were no controlled area radiation signs present. The practice acted immediately and sent evidence following the inspection the services had been booked and the appropriate signage ordered. 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 ineffective systems to manage fire safety. Fire exits were clear and well signposted. However, there was no evidence a fire risk assessment had been conducted by a competent person, weekly smoke alarm testing was not documented, fire extinguishers were not visually inspected monthly and there was no evidence a fire drill had ever been conducted. The practice acted immediately and submitted evidence a fire risk assessment by a competent person had been booked for 2 February 2026 and that a fire drill had been conducted.

Improvements were required to the systems for appropriate and safe management of medicines. In particular, there were no stock control and prescribing logs.

The premises were visibly clean and free from clutter. Hazardous substances were clearly labelled and stored safely. Improvements were required to ensure all safety data sheets were available and substances were used in line with manufacturer’s instructions. In particular, ensuring out-of-date items are disposed of.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. However, we noted 1 staff member had not undergone a disclosure and barring service (DBS) check. The practice submitted evidence of a DBS risk assessment for this staff member.

Improvements were required to the oversight of mandatory staff training, including continuing professional development. We noted multiple mandatory training courses were outstanding for staff. The practice acted immediately and sent evidence the staff members had started to complete the outstanding training courses.

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

There were processes to support and develop staff with roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during practice team meetings and ongoing informal discussions.

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

Staff 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.

Improvements were required to the infection control procedures to ensure they reflected published guidance. In particular, we noted there were multiple un-pouched instruments loose in the surgery drawers and staff were unaware when these were last re-processed.

There were ineffective systems for stock control. In particular, we noted multiple items of out-of-date products and materials which appeared to be in use.

Staff used personal protective equipment and decontaminated dental instruments after use. Improvements must be made to ensure the water temperature is monitored during manual scrubbing and the appropriate logs are completed.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. However, we noted there was no evidence of flushing infrequently used outlets.

The practice had recently completed an infection prevention and control audit. However, we noted this was not dated and not reflective of practice protocols. In addition, the practice had not been carrying these out every 6 months in line with nationally recognised guidance.

Decontamination equipment was maintained and serviced in line with manufacturers’ instructions.

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

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