VitaSmile

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• 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,

recruitment, training, support and development of staff,

and the infection prevention and control standards being followed at the practice,

staff’s understanding, knowledge and awareness of safeguarding.

These concerns were in breach of Regulations 12 (Safe care and treatment), 13 (Safeguarding service users from abuse and improper treatment) 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed) 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 did not have effective systems to identify and manage risks.

Medical emergency medicines and equipment were available in accordance with the Resuscitation Council (UK) (RESUS) guidance. However, the practice did not have systems in place to carry out weekly checks to ensure medical emergency drugs and equipment were available. The current guidance says that practices should carry out at least weekly audits of the medical emergency equipment.

Glucagon, a medication used to treat severe low blood sugar, was kept in the fridge. However, on the day of the inspection the fridge thermometer was not working. This meant that the practice could not be reassured that the medicine was stored at the temperature specified by the manufacturer.

We asked how different medical emergency scenarios would be managed at the practice. The practice principal was unable to clearly describe how medical emergencies would be dealt with. For example, they were unable to identify the symptoms of angina and were unsure which medication would be required in a medical emergency situation.

The practice did not have effective systems in place for the safe use of radiography equipment. 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.

While the intraoral and the Orthopantomogram (OPG) X-ray equipment received annual electro-mechanical servicing on 3 April 2025, we saw no record that the critical examination and/or subsequent routine performance checks had been carried out. The absence of routine performance checks on the X-ray units means faults or deterioration in equipment may go undetected.

Furthermore, the practice could not demonstrate that employer’s procedures and an appropriate risk assessment were in place for the use of radiographic equipment. Local Rules, which should outline safe working practices and administrative controls to manage radiation hazards, were not available for review. Without Local Rules in place, staff may be unaware of critical safety requirements.

The practice appointed a Radiation Protection Advisor (RPA) in December 2025. No previous RPA contracts were available for review. Without a continuously appointed Radiation Protection Advisor (RPA), the practice lacked expert advice to ensure that radiation risks are identified, consistently controlled and managed.

The management of fire safety was not effective. A fire risk assessment dated 1 December 2025 was made available for review. However, the provider was unable to demonstrate that all recommendations identified within the assessment had been implemented.

We requested evidence to demonstrate that, in accordance with the fire risk assessment, the fire alarm and emergency lighting systems had been tested and inspected by a competent person at appropriate intervals. The provider was unable to provide this evidence.

There was a lack of understanding regarding which internal fire safety checks should be carried out. While a log existed for weekly emergency lighting testing, this appeared to be limited to a visual inspection, and the provider unable to demonstrate the correct method for testing the emergency lighting. Furthermore, there were no records demonstrating that the fire alarm system has been properly tested.

The provider told us that fire evacuation drills were not being carried out. This meant that evacuation procedures were untested and staff were unlikely to be familiar with escape routes or their roles.

We noted that 11 out of the 14 members of staff, including the responsible person, had not completed fire awareness training. This increased the risk that staff would not know how to respond appropriately in an emergency.

A lone worker risk assessment, to identify hazards and suitable control measures to protect people working alone at the premises had not been carried out.

While, as required by the Control of Substances Hazardous to Health Regulations 2002 (COSHH), risk assessments were available for some dental materials used by the practice, these were not in place for all substances.

The practice did not have effective systems for monitoring the management of medicines. The service did not maintain a log of antimicrobial prescriptions. Although the principal dentist confirmed that clinicians prescribed antibiotics, they were unable to identify which patients had received medication. This meant that the practice lacked effective oversight to ensure that antimicrobial prescribing was in line with current clinical guidance.

We saw satisfactory records of servicing and validation of the autoclave and compressor in line with manufacturer’s instructions.

The premises were visibly clean, well maintained and free from clutter.

The practice did not have suitable recruitment procedures in place. The practice manager advised that the principal dentist would request recruitment documentation at the point of employment. However, these documents were not logged, and the practice did not maintain records of the recruitment checks undertaken. The provider told us that, following the inspection announcement, a compliance consultant was appointed to compile the recruitment documentation available for the day of the inspection. Prior to this, structured recruitment procedures were not in place.

Records indicated that enhanced criminal record certificates, including suitability information relating to children or vulnerable adults, were missing or unavailable for inspection for 5 of the 14 staff members. A full employment history, including satisfactory written explanation of any gaps in employment, was not available for 9 of the 14 staff members.

Satisfactory evidence of conduct in previous employment for staff who had previously worked in health and social care, or with children or vulnerable adults was not available for 7 out of the 14 staff members.

Following the inspection, we invited the provider to submit any further documents or information they wanted us to consider as part of the inspection. We did not receive any recruitment documentation as part of their response. As a result the provider was unable to demonstrate that the above-mentioned recruitment records were available or that effective recruitment procedures were in place to ensure the required checks and documentation were obtained at the point of employment.

There were no systems in place to ensure staff received induction when they started their new role. Induction records were not available for any members of staff.

Evidence of role-specific training or continuous professional development was not available for 8 out of the 14 staff members. The provider was unable to produce training certificates for a range of mandatory topics, including safeguarding vulnerable adults and children, infection prevention and control, fire safety, radiography, interacting with individuals with learning disabilities or autism, and the Mental Capacity Act 2005.

The training log the provider submitted on 17 March 2026, ahead of the inspection, included record of training for only 1 staff member out of 14. The provider told us that following the inspection announcement, they appointed a compliance consultant who compiled the training certificates available on the day of the inspection. Prior to this, staff training was not centrally monitored.

Following the inspection, we invited the provider to submit any further documents or information they wanted us to consider as part of the inspection. We did not receive any training, induction or performance review documentation as part of the provider`s response. As a result the provider was unable to demonstrate that the above-mentioned records were available or that staff received appropriate support, training, professional development or supervision. Overall, we found that the practice did not have effective systems in place to support staff training and development.

Supervision and monitoring arrangements were ineffective, as the provider had not identified gaps in trainee staff knowledge in relation to infection prevention and control and the management of medical emergencies.

There were no systems in place to ensure staff received regular appraisals of their performance in their role to identify any training, learning and development needs. We requested, but were not provided, recent appraisal or performance review records for any members of staff.

Staff were unable to demonstrate an understanding of the potential signs of abuse or their responsibilities to raise safeguarding concerns both internally and externally. In addition, not all members of staff had completed safeguarding training at a level appropriate to their role. Evidence of safeguarding training was missing for 8 out of 15 staff members and was out of date for 1.

Staff felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “There is a positive working environment where staff contributions are recognised and supported.”

The practice infection control procedures did not reflect published guidance set out in the Department of Health publication ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM01-05). We observed the decontamination of used dental instruments, which did not fully align with national guidance.

A thermometer was available; however, staff were unsure of the correct water temperature required for manual cleaning. Staff were unsure how to correctly use the illuminated magnifying glass for the visual inspection of instruments. Instruments were not fully immersed during the scrubbing process, increasing the likelihood of splashing and potential aerosol contamination. In addition, we observed cross contamination of surfaces during decontamination process.

Overall, there were gaps in staff knowledge and understanding of the relevant guidance. This meant that supervising of trainee dental nurses was not effective as the supervising dentist did not pick up on these shortfalls. Additionally, there were no records available to demonstrate that all staff involved in decontamination processes had received appropriate and up-to-date training.

The practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A Legionella risk assessment dated 1 December 2025 was made available for review. The practice principal was not familiar with the contents of the risk assessment, and they were unable to demonstrate that the recommendations identified within the assessment had been implemented. These included, but were not limited to Legionella management training for all staff involved in Legionella management, covering specific water systems present in the building; ensuring that the recommended weekly, monthly and annual monitoring and maintenance regime is implemented and evidence of checks is recorded; due to the complicated design of the dental unit water delivery system, implementing monthly and quarterly Legionella sampling and converting all dental units to a self-contained bottled water supply.

The Legionella risk assessment identified multiple medium and high-risk issues, yet these have not been acted upon and the person responsible was unaware of them. This means known risks, such as system design flaws, poor maintenance, and inadequate controls, remained unmanaged.

The Legionella Management Logbook included only blank templates and key sections for recording control measure checks, maintenance details, risk assessment updates, safe systems of work, system diagrams, management structure (including responsible persons), and staff training had not been completed.

Infection prevention and control audits were not carried out regularly to identify non-compliance and drive improvement. The only infection prevention and control audit available for review was dated 4 December 2025, with no historical records available. Without regular audits, non-compliance cannot be identified or addressed, allowing poor practices to persist and increasing the risk of unsafe infection prevention and control practices.

We were not assured that the practice was complying with the requirements of Health and Safety (Sharps Instruments in Healthcare) Regulation 2013, which require employers to ensure that risks from sharps injuries are adequately reduced and that appropriate control measures are in place. We did not see evidence that a safer sharps system had been implemented in accordance with these regulations. Some clinicians were using traditional syringes, however, appropriate safety devices, such as needle guards required to minimise the risk of needlestick injuries, were not available.

The staff member, who demonstrated the decontamination of dental instruments, was identified as a non-responder to Hepatitis B vaccination. However, no risk assessment was in place to identify and implement appropriate control measures for this member of staff.

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.