Facedental

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.

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 systems to identify and managed risks and staff described the processes. In-house fire and legionella risk assessments had been completed; however the provider was unable to assure themselves that the persons completing these assessments had received sufficient and suitable training to be able to do so. Following this inspection, we were informed that a legionella risk assessment had been scheduled with an external professional on 20 August 2025 and a date was also being agreed with an external professional to complete a fire risk assessment.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

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 the majority of equipment in line with manufacturer’s instructions. We saw that the Cone Beam Computed Tomography (CBCT) was overdue for the 3 yearly performance check. There was no evidence that electromechanical servicing had been completed on X-ray equipment. This should be completed annually or at a frequency suggested in manufacturers recommendations. Following this inspection, we were sent evidence to demonstrate that the 3 yearly performance check had been scheduled for 9 September 2025 and electromechanical servicing scheduled for 15 August 2025.

The practice had some arrangements to ensure the safety of the X-ray equipment although improvements were required as detailed above. Radiation protection information available included CBCT and X-ray equipment.

There were some systems in place to manage fire safety, although improvements were required. At the time of inspection we saw evidence that the fire alarm had received an annual service. However, there was no evidence of the previous interim, 6 monthly service having been completed. There were no records to demonstrate that regular checking of emergency lighting took place, we saw that this had recently received an annual service. There was no evidence of an electrical installation condition report having been completed within the last 5 years. The fire risk assessment completed by a member of staff at the practice did not identify these deficiencies. The provider assured us that issues identified would be rectified. Fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, we noted that the practice was not working in accordance with their policy on each occasion. Disclosure and barring service checks (DBS) were not available for each staff member as required. Following this inspection, we were provided with evidence to demonstrate that missing DBS checks had been applied for.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. However, systems to monitor staff training required strengthening as the Registered Manager did not have evidence of all training completed by all staff. Following this inspection, we were sent evidence that all staff were registered on the practice’s compliance system and had started to update training as required.

Some newly appointed staff had an appropriate role specific structured induction. We saw that documentation was available and were assured that this would be used going forward.

Staff 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. We were assured that staff knew how to escalate safeguarding concerns within the practice and externally.

The systems in place to ensure that staff training, including continuing professional development, was up-to-date and reviewed at the required intervals required strengthening. The Registered Manager assured us that systems would be implemented going forward to ensure that staff training was monitored more frequently.

There were effective 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 and ongoing informal discussions.

Staff 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 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 limited evidence to demonstrate that the person completing the risk assessment had sufficient knowledge of applicable legislation and had received suitable training regarding legionella. Following this inspection, an external professional company was contacted and a risk assessment scheduled for 20 August 2025.

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

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice was not completing infection prevention and control audits at the frequency suggested in current guidance. We saw that some issues for action identified in the 2024 audit were still identified as outstanding in the 2025 audit. Following this inspection, we were assured that the outstanding issues would be addressed and that these audits were scheduled 6 monthly going forward.

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