Catherine Street Dental Practice

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 providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

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, but improvement was needed to ensure processes were effective.

The practice had not carried out risk assessments in relation to the safe storage and handling of every substance hazardous to health that was in use by staff.

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

Checks of emergency equipment and medicines did not follow national guidance to ensure availability and suitability for use. We noted a number of items of emergency equipment was not present.

Medical emergency oxygen checks were ineffective. The cylinder was not the recommended size and was 30% full. Evidence to confirm it had been serviced was not available. Since our inspection we have received evidence which confirms this shortfall has been addressed.

Improvement was needed to ensure the non-refrigerated storage arrangements for Glucagon (an emergency medicine used to regulate blood sugar levels) followed manufacturer’s guidance. Since our inspection we have received evidence which confirms this shortfall has been addressed.

The practice had not implemented systems to assess, monitor and manage risks to patient and staff safety. In particular, the management of lone working and sepsis.

The premises were visibly clean and free from clutter and environmental cleaning schedules, specific to the practice, were available. However, oversight of environmental cleaning standards could not be demonstrated.

The practice had arrangements to ensure the safety of the X-ray equipment, but improvement should be made to ensure that servicing of equipment was carried out in line with manufacturer’s instructions.

The X-ray unit was serviced in September 2026. The provider could not provide any previous service records but felt it was a couple of years since the last service.

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 compressor was serviced in September 2026. The provider could not provide any previous service records but felt it was a couple of years since the last service.

The practice’s oversight of fire safety management procedures was not effective. Specifically testing of equipment and signage and fire drill reporting.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable 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 told us that there were enough staff on duty at all times.

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.

Oversight of staff training, including continuing professional development required improvement. Specifically, safeguarding, fire safety, basic life support and interacting with someone who has a learning disability and autistic people training is required to be carried out by both clinical and non-clinical staff.

Staff discussed their learning needs, general wellbeing and aims for future professional development during ongoing informal discussions.

The practice could not assure themselves that all of the clinical staff had immunity to the Hepatitis B virus. Evidence to confirm the effective of the hepatitis B vaccinations was not available for 2 staff.

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

The practice’s infection control procedures reflected published guidance, but improvement was needed.

Environmental cleaning equipment storage arrangements did not follow national infection prevention and control guidelines.

Out of date dental products were found in both treatment rooms 1 and 2.

Evidence to confirm that staff had oversight of the standards of clinical area cleaning was not available.

Not all staff used appropriate personal protective equipment when working in clinical areas.

The manual cleaning process and procedure did not follow national HTM01-05 infection control guidelines.

We saw, and staff confirmed that single-use items were not reprocessed.

A legionella risk assessment was carried out in 2011. The provider was unable to evidence that the resulting action plan had been completed.

Evidence was not available to confirm that little used water outlets (taps) were flushed twice weekly in line with the Legionella risk assessment action plan.

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

The practice completed infection prevention and control audits in line with current guidance.

An annual infection prevention and control (IPC) statement was not available.

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