Mr. Nigel Monkman Also known as Nigel Monkmans 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 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,

adequacy and availability of emergency equipment and medicines,

recruitment, training, support and development of staff,

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

These concerns were in breach of Regulations 12 (Safe care and 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.

Not all medical emergency medicines and equipment were available in accordance with the Resuscitation Council (UK) guidance. The practice did not have Oromucosal Midazolam, a medication used to treat prolonged epileptic seizures, or a bodily fluid spillage kit. In addition, there were no systems in place to ensure that Glucagon, a medication used to treat severe low blood sugar, was kept at the temperature specified by the manufacturer. Furthermore, improvements should be made to ensure that weekly checks were consistently documented to confirm the availability and readiness of all required emergency medicines and equipment.

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

We did not see satisfactory records of servicing for the autoclave and the compressor. The most recent servicing record for the autoclave was dated 10 February 2014, and no servicing records were available for the compressor, which the provider told us was serviced in-house. Autoclaves and compressors operate under pressure and, if not properly installed, examined, and maintained can fail, leading to release of pressurised steam or air.

Improvements were needed to ensure that both the autoclave and compressor received regular servicing in line with the manufacturer’s guidance or in the absence of this, in line with the current guidance set out in Department of Health publication ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM01-05).

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.

There were no servicing records to demonstrate that effective systems were in place to ensure the X-Ray unit was safe to use. Therefore, we were not assured that the provider understood the required testing schedule or their responsibilities in relation to radiation safety. The absence of routine performance checks and up-to-date surveys on the intraoral X-ray unit 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. Additionally, there was no evidence that the practice had registered their work with a radiation generator with the Health and Safety Executive (HSE). In response to our inspection feedback, the provider submitted documentation in relation to HSE registration. However, this documentation appeared to consist of guidance on how to submit a registration, rather than confirmation that a registration application had been completed or a valid registration certificate.

The practice had not carried out risk assessments for hazardous materials used within the practice as per Control of Substances Hazardous to Health Regulations 2002 (COSHH). Without risk assessments, there is no systematic identification of potential hazards. In addition, staff did not have access to the safety data sheets of hazardous materials used within the service.

The practice did not comply with the requirements of the Health and Safety (Sharps Instruments in Healthcare) Regulation 2013, which require employers to ensure that the risks associated with sharps injuries are adequately assessed and that appropriate control measures are in place. The practice could not demonstrate that a risk assessment had been carried out to assess the risks associated with the use of sharps. Additionally, we did not see that a safer sharps system had been implemented in accordance with the relevant legislation.

The management of fire safety was not effective. A fire risk assessment had not been completed to adequately identify the nature and use of the premises, emergency routes and exits, firefighting equipment, an emergency fire evacuation plan, the needs of vulnerable people or staff training requirements. Without a suitable fire risk assessment, hazards may go unidentified and unmitigated. Fire evacuation drills were not carried out, and no documented evacuation procedures were in place.

The practice had 1 battery operated smoke detector. However, there was no evidence of routine in-house testing to ensure it was operational. The practice had one CO2 fire extinguisher, with no records available to confirm servicing or maintenance. Without routine testing and regular servicing, there is no assurance that the fire safety equipment will operate in the event of a fire.

Fire exits and doors were not clearly signposted, and it was not clear which doors were fire resistant doors.

The practice did not have emergency lighting, and there was no evidence to demonstrate that the requirement to illuminate fire escape routes had been assessed.

Additionally, there was no evidence of fire awareness training for any members of staff.

The Electrical Installation Condition report (EICR) carried out on 24 January 2026 rated the safety of a premise electrical system ‘Unsatisfactory’ and included 2 observations as ‘potentially dangerous’ and 12 areas requiring improvement. No historical electrical safety records were available for review.

A current gas safety certificate was not available for review. Additionally, no historical gas safety records were available to provide assurance that gas appliances had been inspected or maintained in accordance with regulatory requirements.

The practice had systems for appropriate and safe management of medicines. Prescription only medication was kept securely and there was an effective stock control system in place.

The practice did not have suitable recruitment procedures in place. The provider told us that the practice did not have a recruitment policy and that formal recruitment checks had not been undertaken.

A copy of an enhanced criminal record certificate with suitability information relating to children or vulnerable adults was not available for review for 6 out of the 7 staff members.

Satisfactory evidence of conduct in previous employment concerned with services relating to health and social care, or work children or vulnerable adults, was not available for any members of staff.

A full employment history, together with a satisfactory explanation of any gaps in employment, was not available for 6 out of the 7 staff members.

Proof of identity, including a recent photograph, was not available for any members of staff.

Following the inspection and in response to our feedback, 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 the provider`s response 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 4 out of the 7 staff members. This included but was not limited to evidence of training in safeguarding vulnerable adults and children, medical emergencies, infection prevention and control, fire safety, radiography, interacting with people in learning disability or autism, and the Mental Capacity Act 2005. When asked, the provider told us that they did not have access to staff training records, as staff were responsible for managing their own training. This meant that there were no systems in place to ensure that all core and role-specific training had been completed or to enable timely action where training requirements had not been met.

We also found that supervision and monitoring of staff working in the service were not effective in that the provider did not identify gaps in staff knowledge relating to infection and prevention and control.

There were no systems in place to ensure staff received regular appraisal 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. The most recent appraisal records available for review were dated 2014.

Overall, we found that the practice did not have effective systems in place to support staff induction, training, supervision, appraisal, or ongoing professional development.

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.

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

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 align with national guidance.

Staff did not wear appropriate Personal Protective Equipment (PPE). Heavy-duty gloves were not available in Surgery 1, and staff had to be prompted to wear a protective apron. A thermometer was not used to ensure water used for manual cleaning was under 45°C, as required.

Staff used a wired brush to scrub instruments, as a long-handled brush was not available in Surgery 1. The use of wired brushes can damage instruments and increase the risk of sharps injuries and contamination.

Instrument sterilisation was carried out in the kitchenette where staff prepared food and drinks. This arrangement had not been risk assessed to ensure adequate separation of decontamination activities from other uses, either by physical or temporal means.

Systems to monitor storage time of sterilised instruments were ineffective. We saw unwrapped instruments kept in the clinical area, and the practice could not demonstrate that there were systems in place to ensure these items were reprocessed at the end of the day. In addition, many sterilisation pouches were not dated, and multiple instruments of the same type were packaged together, increasing the risk of contamination during retrieval. When we brought this to the provider`s attention, staff immediately re-pouched and re-sterilised some instruments. However, we were not assured that staff had sufficient knowledge of the relevant guidance in relation to safe storage of sterilised instruments. Additionally, no records were available to demonstrate that all staff involved in decontamination processes had received appropriate and up-to-date training.

Records confirming Hepatitis B immunity were also not available for 6 of the 7 dental staff members, and the provider was unable to demonstrate that the associated risks had been assessed or mitigated. This places staff at an increased risk of contracting infections, including through needle-stick injuries or contact with contaminated sharps.

Staff did not carry out routine testing of the ultrasonic cleaners, including protein residue, foil, or soil tests, in line with manufacturer’s guidance or, where this was unavailable, in accordance with HTM 01-05. The absence of routine testing and monitoring of ultrasonic cleaners means there is no assurance that cleaning processes are effective as intended.

There was no documented cleaning schedule in place to monitor the effectiveness of cleaning. During the inspection, we saw cobwebs in Surgery 2.

The practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A Legionella risk assessment, completed by a competent person was not available for review. Without a Legionella risk assessment, there is no systematic identification or control of conditions that allow bacterial growth, such as stagnation, temperature, or biofilm buildup in water lines. Additionally, a written waterline management scheme was not available to demonstrate how water systems are monitored, cleaned, or maintained to reduce the risk of bacterial contamination.

The practice had some protocols for the segregation and disposal of hazardous waste. However, these procedures were not always safe or in line with the relevant national guidance. The practice used wet film processing to develop dental X-Rays. Staff told us that the developer solution was disposed of by pouring it down the sink. Pouring developer chemicals down the sink can contaminate water systems and the environment, as the substances are not designed to be disposed of via standard drainage systems.

Infection prevention and control audits were not carried out to identify non-compliance and drive improvement. The most recent audit available for review was dated 2014. The absence of regular audits means risks may not be identified, monitored, or addressed in a systematic way.

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