Poldent Dental Care

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:

Safe and effective recruitment of staff and oversight of training, support and development of staff.

The safety of the premises in relation to fire safety, and the oversight of infection prevention and control processes being followed at the practice.

Understanding, and acting on safeguarding concerns.

These concerns were in breach of Regulations 13, 15 and 17 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 provider did not ensure they had robust procedures to make sure people are protected, concerns documented, and where appropriate, shared quickly and appropriately.

The provider had a safeguarding policy in place, but this was not followed. The policy was generic and did not include the types of safeguarding staff may encounter. We signposted them to additional resources to support them. A separate document included up-to-date contact information for local safeguarding organisations.

We saw staff completed safeguarding training to the appropriate level and updated their training at appropriate intervals, but the provider did not maintain oversight of this. The induction procedures included ensuring staff were familiarised with safeguarding arrangements, but there was no evidence this process was followed for 6 members of staff.

Staff were not always aware of their responsibilities for safeguarding vulnerable adults and children. Staff knew how to escalate safeguarding concerns within the practice. However, the named safeguarding lead was not aware of the requirements of their role or responsibilities. Two examples were described to us where staff had fulfilled their responsibility to raise concerns to the named practice safeguarding lead.

We asked to see evidence that the safeguarding issues raised had been dealt with according to their policy. These incidents were not documented in the events log and there was no evidence of discussion, investigation, or consideration whether concerns should be shared with external organisations.

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 processes to identify and manage risks.

The management of fire safety was ineffective. The fire alarm service report from October 2024 highlighted significant faults with the system which affected its function. These were not brought to the attention of the owners until April 2025, and during the inspection, we confirmed they were yet to be addressed.

In addition, fire drills had not been carried out since February 2023, staff did not carry out visual checks of the emergency lighting and emergency lighting had not had annual full duration testing carried out. Fire extinguishers were in place and serviced annually. Fire exits were clear and well signposted. After the inspection the emergency lighting annual duration testing was booked and a fire drill was carried out.

The oversight of servicing of equipment in line with manufacturer’s instructions was ineffective as records of servicing were missing. These had to be obtained and provided after the inspection for the steriliser and fire extinguishers. Routine servicing of 2 intraoral X-ray machines had not been carried out at the recommended intervals.

The practice mostly had effective arrangements to ensure the safety of the X-ray equipment, but the required radiation protection information was not available. The critical examination report for the cone-beam computed tomography (CBCT) machine was not available. This was provided after the inspection and we saw the recommendations had been acted on. 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.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. We highlighted the aspirin in the kit was not in the recommended form (dispersible).

The premises were visibly clean and well maintained. Hazardous substances were clearly labelled and stored safely. A sharps risk assessment was in place, but this did not include all sharps in use at the practice.

The practice had systems for appropriate and safe management of medicines.

Recruitment procedures were not operated effectively to ensure that appropriate checks were carried out before employment and to maintain up-to-date staff records.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. The infection prevention and control policy also included procedures to follow in relation to vaccination and immunity checks for clinical staff. These policies were not followed.

The practice did not consistently carry out checks that clinical staff were appropriately qualified, held current registration with the General Dental Council and had appropriate professional indemnity cover in place.

Right to work checks had not been carried out for 3 members of staff who required these.

Disclosure and barring Service (DBS) checks had not been actioned at the point of employment for 7 staff members.

Evidence of satisfactory experience and conduct in prior employment was not consistently sought for clinical staff.

The provider did not obtain satisfactory evidence of immunity to Hepatitis B for 3 clinical staff members.

After the inspection the manager obtained evidence of indemnity and confirmed right to work and immunity checks were now in progress.

There was a process to ensure newly appointed staff had an appropriate role specific structured induction. There was no evidence of this being followed for 6 members of staff.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff.

We saw staff training, including continuing professional development, was up-to-date. However, this had to be requested from staff prior to our visit. Improvements should be made to maintain routine oversight of this.

Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, 1-to-1 meetings, practice team meetings and ongoing informal discussions.

The practice had infection control procedures that reflected published guidance. These should be reviewed to ensure staff are clear on the processes to be followed. In particular, we were told, and saw staff were not routinely using the correct steriliser cycle, and staff were not aware of the difference between the cycles. The manager confirmed this would be discussed with staff and addressed.

Staff received training and carried out appropriate validation tests on decontamination equipment. The equipment in use was maintained and serviced as per manufacturers’ instructions.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. We saw dental unit waterlines were clean. However, staff did not use the water conditioning solution in line with the manufacturer’s instructions, and staff we spoke to were unaware of the indicators that water quality could be deteriorating. We signposted them to resources to support them.

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

The practice completed infection prevention and control audits in line with current guidance. We highlighted the work surfaces in the decontamination room should be decluttered to provide room for staff to process instruments and maintain cleanliness effectively.

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