Brownhills 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.

Although there were issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk.

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 identified and managed some risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice and although this was not always reflected in our findings, the provider devised an action plan to address the shortfalls we found during the inspection.

We did not see evidence staff were checking emergency equipment and medicines in line with national guidance, and we found out of date items and incorrectly stored medicines. The provider sent us evidence these items had been ordered following the inspection.

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, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We identified shortfalls with the practice arrangements to ensure the safety of the X-ray equipment. We did not see the critical examination and acceptance testing report for the 2 handheld X-ray units. The electromechanical servicing was overdue for one of the intraoral X-ray units and the OPG Orthopantomogram unit.

The provider sent us evidence following the inspection that the servicing of the machines had been scheduled to be carried out on 8 September 2026. There was no radiation signage on 3 of the treatment room doors. The provider addressed this following the inspection. The local rules needed updating as they contained out of date radiation protection supervisor details and local rules needed to be implemented for the handheld X-ray units. 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 systems to manage fire safety needed strengthening. The fire alarm was serviced in September 2025. This should be serviced every 6 months. The provider told us they were advised by a fire safety officer they could delay the fire alarm service until they had completed the recommended upgrades to the system, however we did not see evidence this work had been scheduled. The routine internal fire checks did not include emergency lighting or fire extinguisher checks. The provider was not carrying out fire evacuation drills. The provider sent us evidence following the inspection to demonstrate they had updated their fire safety checklists to include all checks.

The practice mostly had systems for appropriate and safe management of medicines. We highlighted that improvements could be made to the tracking system used to reduce the risk of prescription theft or misuse. The provider sent us evidence they had implemented an effective system to address this following the inspection.

The providers recruitment procedure to help them employ suitable staff, did not reflect relevant legislation. Not all staff had references or Disclosure and Barring Service (DBS) certificates in place.

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

We did not see evidence that all 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 always enough staff on duty. 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. Following a discussion around safeguarding procedures during the inspection the provider sent evidence they had scheduled a team meeting to train staff on the ‘Was not Brought’ policy and procedures.

Although some staff had completed all the recommended training, the practice did not have a system to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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. We discussed the value of minuting all meetings so that staff who could not attend had the opportunity to see a record of the discussions, decisions and actions agreed.

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

The practice had infection control procedures that 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 saw, and staff confirmed that single-use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice had not completed infection prevention and control audits in line with current guidance. The previous 2 audits had been completed 15 months apart. These should be completed every 6 months. The audit did not identify the issues we found during the inspection such as tears in the dental chairs.

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