Kirkholt Dental 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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

Whilst 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 had some processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice.

Emergency medicines were available in accordance with national guidance. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

We noted that checks on emergency equipment were not in accordance with national guidance, as a result, some equipment was missing. All missing equipment was ordered during the inspection day, and a new weekly medical emergency kit checklist was created during the inspection.

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 equipment in line with manufacturer’s instructions. The dental compressor was overdue it’s pressure vessel inspection. Evidence was sent after the inspection this was booked for 11 November 2025.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. We noted recommendations in 2 of the equipment installation reports relating to the walls between surgeries and the direction of the beam towards a ground floor window. There was no evidence these had been reviewed and the radiation protection advisor’s advice sought.

The day-to-day management of fire safety was effective, and fire exits were clear and well signposted. Staff carried out safety checks of equipment which was serviced regularly. Following a fire risk assessment in 2023, recommendations had not been actioned or risk assessed. The managers told us they had considered some of these recommendations, but as nothing had been documented, this could not be evidenced.

Recommendations included relocating a fire extinguisher as a priority, providing additional signage, gaps around fire doors, training for staff and the location of the fire alarm panel. The managers were unclear on the meaning of some of the recommendations, but clarification had not been sought at the time of the report being received to ensure the correct action was taken within the specified time period. After the inspection, action was taken to book an updated premises fire risk assessment. The managers provided assurance any recommendations will be actioned promptly.

The practice had systems for appropriate and safe management of medicines. A log was in place to monitor and track the use of NHS prescription pads. We highlighted the pads in surgeries should be held securely when not in use.

The practice had a recruitment policy that reflected relevant legislation, to help them employ suitable staff. However, this was not followed consistently.

The practice ensured clinical staff were qualified. The systems to ensure staff remain registered with the General Dental Council and hold appropriate professional indemnity cover should be reviewed. Some documents held on file had expired.

Right to work checks were not carried out where appropriate, and Disclosure and Barring Service (DBS) were not consistently carried out at the point of employment. Professional references where appropriate, were not always sought.

Not all newly appointed staff had an appropriate role specific structured induction.

After the inspection, the manager sent updated employment checklists to ensure all checks specified in the policy are carried out consistently.

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. 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.

Practice staff showed their effective use of a national toolkit to support the safeguarding of children and young people who are not brought to appointments, and reinforcing the importance of bringing them to appointments had reduced the frequency of this occurring. We saw detailed logs of safeguarding concerns highlighted, with information shared appropriately with the local safeguarding team and school nurses where appropriate.

The arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals should be reviewed. The practice asked for dates when training was completed but did not view certificates to assure themselves of the content or level of the training where appropriate.

Four staff members had not received fire safety training, 2 had not provided evidence of appropriate safeguarding training and evidence of appropriate radiography and radiation protection update training had not been requested from the clinicians. We also highlighted the benefits of staff receiving training on sepsis awareness, Legionella awareness, and autism and learning disability awareness.

There were 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, during clinical supervision, practice team meetings and ongoing informal discussions.

Staff stated they 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 were unsure whether protein residue testing was required for the washer disinfector. We were told these had previously been performed but not recorded.

After the inspection, evidence was sent that clarification was sought from the device manufacturer which confirmed these tests should be carried out. New test packs had been ordered and a log created to ensure these can be evidenced.

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 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.

The equipment in use was maintained and serviced as per manufacturers’ instructions.

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.