Langmans at Ely Place Dental Health Centre

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 are 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 risks and staff described the processes, although there was lack of oversight to ensure that some risks identified had been acted on. Some issues for action remained outstanding on the legionella and health and safety risk assessments. The practice had not documented actions taken to address issues identified or justification for not addressing these issues.

Staff could access emergency equipment and medicines. Improvements were required to the frequency of checks to ensure compliance with national guidance. We were assured that weekly checks would be made going forward. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff providing treatment to patients under sedation had also completed immediate life support training.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. At the time of our inspection there was no evidence that the autoclaves in use had been appropriately validated in accordance with relevant requirements. The provider acknowledged this and provided assurance that validation data would be downloaded, reviewed, and recorded routinely going forward to ensure effective oversight of the equipment.

The practice had some arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT). The provider has given assurances that recommendations identified within the annual servicing report would be completed. A CBCT machine had been newly installed in May 2026, and the Radiation Protection Adviser (RPA) had recommended that a risk assessment be completed and specific local rules developed for the equipment. Quality assurance checks relating to image quality and display screens were also required. The provider assured us that these matters would be addressed.

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 systems in place to manage fire safety, although some improvements were required with the systems in place for in-house checks. All fire safety equipment had received regular servicing in line with requirements. However, records were not available to demonstrate that regular in-house checks were all being completed. Following this inspection, we were sent assurance that these in-house checks would be completed. During the inspection, fire exits were observed to be clear and appropriately signposted.

The practice had systems for appropriate and safe management of medicines. Further information was required to be included on medicine dispensing labels to ensure they contained all relevant details. We were assured that this would be addressed immediately. NHS prescription pads were stored securely; however, improvements were required to logs kept. Following this inspection, we were sent evidence to demonstrate that the monitoring log to ensure NHS prescriptions could be effectively tracked and accounted for had been updated.

The practice had a recruitment policy that reflected relevant legislation, to help them employ suitable staff. Evidence of Disclosure and Barring Service (DBS) checks, hepatitis B levels and photographic identification was available for some but not all staff. The provider should implement an effective recruitment procedure to ensure that appropriate checks were completed prior to new staff commencing employment at the practice. We were told that appropriate DBS checks had been reviewed and verified at the time of employment within the practice but evidence was not available to confirm this.

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 had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. 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.

The practice had systems in place to support staff training and continuing professional development; however, oversight required improvement. At the time of inspection, evidence was not readily available to demonstrate that all staff had completed all mandatory training, and the training records reviewed contained some gaps. We saw evidence that the Compliance Manager had been actively requesting outstanding training certificates from staff. The practice advised that a new system was being introduced to strengthen oversight and provide greater assurance that training is completed and recorded appropriately.

There were effective processes to support and develop staff with additional roles and responsibilities. Some dental nurses had completed training for extended duties such as intra oral scanning. A receptionist had a dual role as the purchasing and equipment manager. Staff had been allocated lead roles such as head and deputy head dental nurse, infection prevention and control lead, Was Not Bought Champion and Freedom to Speak Up Champion.

Staff felt respected, supported and valued, and they were proud to work in the practice. We were told, “I feel staff are supported well and the practice does its best to help when it can.”

The practice had infection control procedures that reflected published guidance.

Staff had access to appropriate training although evidence was not available for all staff to demonstrate that this training had been completed within the required timeframe. Staff spoken with 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 procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. There was no action plan to demonstrate actions taken or justification given for not addressing the 2 issues identified in the legionella risk assessment. However, we were told that these issues would be addressed.

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

Equipment was serviced in accordance with the manufacturers’ instructions. There was no information available to demonstrate that each autoclave was functioning correctly within the required temperature and time requirements. There was no evidence of staff completing the required validation checks, the provider was unable to demonstrate that the equipment was being monitored effectively, although we were told that visual checks were completed but not recorded.

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

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