Implant and Aesthetic Center Limited

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 tothe safety of the equipment, adequacy and availability of emergency equipment and medicines, management of medicines, and infection prevention and control standards not being followed at the practice. In addition, we found concerns related to the recruitment of staff and the ability of staff to effectively manage potential safeguarding incidents.

These concerns were in breach of Regulation 12, Safe care and treatment and Regulation 17, Good governance.

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 have effective safeguarding processes in place.

Staff we spoke with did not have access to the required information to refer a safeguarding incident/concern to the appropriate external agencies. They told the inspection team that if they suspected a safeguarding concern, they would inform the safeguarding lead of the practice. The safeguarding lead was the registered manager, but they were not routinely on site, only attending on average once a month. We were unable to see evidence of a protocol on how staff would escalate a safeguarding concern in a timely manner to an external agency.This limited the effectiveness of safeguarding processes and staff confidence in responding to safeguarding concerns.

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 identify and manage risks effectively. A fire risk assessment, health and safety risk assessment and Legionella risk assessment had been completed by an external company on 21 November 2025. However, the practice had not addressed the urgent recommendations listed within the action plans of each risk assessment. These included but were not limited to, performing in-house testing of the fire safety equipment, undertaking fire drills, displaying hot water signage and descaling of taps. Although the service had completed a sharps risk assessment, the sharps bin in one of the treatment rooms was overfilled and posed a sharps risk to staff. In addition, staff did not have access to occupational health contact details in the event of a sharps injury. Staff knowledge around identifying and escalating suspected sepsis needed improvement. No staff members had completed training in sepsis.

Emergency equipment and medicines were not easily accessible or maintained in line with national guidance. Weekly checks had not been carried out, and many essential items were missing, including oxygen. The practice did not have sufficient quantity of midazolam, which is a medicine used to treat seizures. They also lacked the appropriate equipment to administer adrenaline to effectively treat anaphylaxis, and there was no spacer device which is used to help administer medicines to treat asthma attacks. Although staff told us they knew how to respond to a medical emergency, they had not participated in medical emergency scenario training and were unaware that essential items were not available in the medical emergency kit for them to effectively treat a potential medical emergency.

Records of servicing and validation of the autoclaves, X-ray units and compressors were not available to review. This meant that the service could not be assured that they were working safely and effectively.

Arrangements to ensure the safety of the X-ray equipment were inadequate and the required radiation protection information was not available. Although the practice was able to demonstrate payment to a radiation protection consultancy service, staff were unaware of what the service provided and did not know if a Radiation Protection Advisor (RPA) or Medical Physics Expert (MPE) had been appointed. Staff were also unable to confirm whether the X-ray units had undergone annual servicing or the required 3-yearly critical examination. In addition, the practice had not registered with the Health and Safety Executive for work with radiation generators. 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.

Hazardous substances were clearly labelled, but not all were stored safely. Cleaning products were stored in an unlocked cupboard within the patient bathroom and staff did not have access to safety data sheets in line with Control of Substances Hazardous to Health Regulations 2022.

The arrangements to assess and mitigate the risks of fire at the practice required improvement. We reviewed a fire safety risk assessment dated 21 November 2025. Urgent recommendations that were made remained unaddressed at the time of the inspection. The fire safety equipment was not subjected to regular in-house testing to ensure it was in good working order and staff had not participated in fire evacuation drills.

However, the premises were visibly clean, well maintained and free from clutter.

The practice had a recruitment policy, but this did not fully reflect relevant legislation and did not take into account agency or locum staff.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had professional indemnity cover. However, clinical staff only had basic Disclosing and Barring Service (DBS) checks and not the required enhanced DBS checks. Right to work in the UK checks had not been completed for any staff member. Prior to our inspection, we were informed that only 3 clinicians worked at the practice. However, the inspection team noted that another dentist was providing treatment to patients the day after our visit. Recruitment documents for this dentist were not available for review. The inspection team carried out their own checks to assure themselves that this dentist was registered with the GDC.

The practice used agency nurses on a regular basis. We did not see evidence that the practice had obtained assurances from the agency that the appropriate pre-employment checks had been completed, to ensure agency staff were fit and proper to work. In addition, agency nurses did not receive an adequate role specific structured induction, particularly in the decontamination of dental instruments.

Staff had completed continuing professional development, which was mostly up-to-date. Improvements were required to ensure staff had completed training in sepsis.

There were effective processes to support and develop staff with additional roles and responsibilities. One staff member said, “I am regularly involved in discussions around clinical development, new treatments, equipment and patient care pathways. My views are actively sought and considered when planning improvements.” Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “My role is recognised as important to patient experience and I feel valued as part of the team.”

Infection control procedures did not reflect published guidance.

The agency nurse demonstrated knowledge and awareness of infection prevention and control processes, however, local operating procedures and oversight of the decontamination process required improvement. There was no apron or heavy-duty gloves for the nurse to use as personal protective equipment (PPE) while decontaminating dental instruments, and the layout of the decontamination room was not in line with national guidance. In addition, essential equipment was not available. There was no measuring jug to ensure the correct concentration of detergent was used, no long-handled brush for manual cleaning of instruments, and no thermometer to confirm that the water temperature used during manual cleaning met recommended standards. The autoclaves had not been maintained and serviced in line with manufacturers’ instructions.

Single-use items, such as healing caps for implant abutments were reprocessed in the autoclave and re-used, which is not in line with national guidance

The practice had completed a Legionella risk assessment in November 2025, but had failed to act on the recommendations within the action plan, including descaling taps. Furthermore, there were no records to demonstrate that staff monitored the temperatures of the hot and cold sentinel taps, to reduce the risk of Legionella, or other bacteria developing in water systems.

The practice completed infection prevention and control audits in line with current guidance, but these audits did not reflect our findings on the day of our inspection and failed to identify areas of required improvement.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. Improvements were required to ensure sharps bins were not overfilled, which could pose risks of sharps injury to staff.

The provider did not have systems in place for the appropriate and safe handling of medicines.

The inspection team found loose medicines stored out of their original packaging and within a pencil case. These medicines were not stored securely and the practice did not have a robust system in place to log, monitor or track all medicines held on site.

The provider did not have an effective stock control system for the medicines. Several medicines held at the practice had passed their expiry date, including some that had expired in August 2024.

Staff were not aware of current prescribing guidelines and the practice’s antimicrobial prescribing audit had not identified that prescribing was not in line with this guidance.