Greg Gossayn Dental Surgery

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.

The provider had made improvements in relation to the regulatory breach of Regulation 19 we found at our assessment on 15 January 2025.

However, the provider had made insufficient improvements to put right the shortfalls to the regulatory breach of Regulation 12 we found at our assessment on 15 January 2025. We have told the provider to take action. We will be following up on our concerns to ensure they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service.

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.

At the assessment on 7 March 2025, we found the practice had made the following improvements to comply with the regulation:

The practice had improved their processes to identify and manage risks. The practice had carried out a health and safety risk assessment to identify and mitigate specific risks relating to the practice and had completed a risk assessment to assess and mitigate the risks associated with the use of sharps, in line with Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

Emergency equipment, including an Automated External Defibrillator (AED), and most medicines were available as advised in guidance issued by the Resuscitation Council UK. The medical emergency kit had a few missing items that were ordered immediately. Staff told us they knew how to respond to a medical emergency and had completed online training in emergency resuscitation and basic life support. Face to face training had been organised for all staff to be completed in April 2025.

The management of fire safety had improved. A fire risk assessment had been carried out on 30 January 2025 by an external company and the practice had addressed the actions outlined in this risk assessment. The practice had completed another risk assessment to address the risks associated with the building works which were ongoing in the practice and aimed to further review the fire risk assessment once the building works had completed. The practice assured us that an Electrical Installation Condition Report (EICR) would be scheduled once the building works had been completed.

Electromechanical servicing and 3 yearly performance checks had been completed on the intra-oral and orthopantomogram (OPG) x-ray machines on 25 February 2025. One of the intra-oral x-ray machines had been decommissioned following these performance checks. Local rules for the OPG had been developed in February 2025, which identified key working instructions to ensure that exposure of staff and others to radiation was restricted. The practice had notified the Health and Safety Executive that they worked with ionising radiation and had appointed a Radiation Protection Advisor and Medical Physics Expert. The practice had carried out a radiation risk assessment. Further improvements were required to ensure that all actions outlined within the recent electromechanical survey, including securing the OPG, had been actioned. The practice made arrangements for the OPG to be secured immediately following our assessment.

Improvements were required as the practice had not fully assessed and mitigated the risks associated with lone working. The lone worker risk assessment stated that there should be 2 staff members trained in medical emergencies on site at all times, however, this was not always followed. Following feedback from the inspection team, the compliance manager assured us that all future appointments would be booked in line with their risk assessment.

While cleaning products were stored securely, not all dental materials and cleaning products had up to date risk assessments or safety data sheets accessible to staff, in line with Control of Substances Hazardous to Health (COSHH) Regulations 2002.

At the assessment on 7 March 2025, we found the practice had made the following improvements to comply with the regulation:

The practice had developed a recruitment policy and procedure which reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. Since our last inspection, the practice had employed a compliance manager who had developed induction checklists to help new or agency staff with induction and had implemented systems to monitor staff’s fitness to work, including but not limited to; up to date Disclosing and Barring Service checks and evidence of immunity to Hepatitis B, including the level of response (titre levels).

The practice’s new compliance manager had developed systems to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. The principal dentist referred some implant patients for cone beam computed tomography (CBCT). As they had not completed the required training, future CBCT scans would be reported on externally by trained operators. The practice had developed processes to support and develop staff with additional roles and responsibilities. The dental nurse had been supported to complete further training in infection prevention and control and had been nominated as the Infection Prevention and Control Audit Lead.

At the assessment on 7 March 2025, we found the practice had made the following improvements to comply with the regulation:

The practice appeared clean, and environmental cleaning logs had been completed consistently. The practice had taken action to address the recommendations from the previous Legionella risk assessment. Improvements were required to ensure records were maintained for the temperature of the cold water from the sentinel taps. A new Legionella risk assessment would be required once the building works had been completed, taking into account the changes made with the building works.

The practice had completed infection prevention and control (IPC) audits in line with current guidance and the dental nurse had completed IPC leader training. The inspection team observed that the damaged chair had been replaced, and local anaesthetic cartridges were stored in their original blister packs.

We observed the decontamination of used dental instruments, and acknowledged it had improved, but still did not fully align with national guidance issued by the Department of Health in the publication ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM01-05). The practice had introduced systems and processes to monitor the use of heavy-duty gloves and long handled brushes used to manually clean the instruments. The worksurface used to store the vacuum autoclave had been decluttered, to improve the dirty to clean flow to avoid cross contamination.

The practice had purchased a thermometer to monitor the temperature of the water used for manual cleaning of the contaminated dental instruments. However, this was not always used to ensure the water was below 45 degrees Celsius and the instruments were not fully submerged during manual cleaning. In addition, the inspection team saw that not all dental instruments had been pouched, and we did not see evidence that they were re-processed each day in line with HTM01-05 guidance.

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