Pinner Road Dental Practice

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:

the safety of the premises and equipment

safe and effective recruitment of staff

management of people's medicines and prescriptions

These concerns were in breach of Regulation 12 Safe care and treatment.

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 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 management of risks required improvement This included fire safety and sharps safety.

The sharps risk assessment was not reflective of practice processes. It described the use of safer sharps which the practice did not stock or use.

Staff could access most emergency equipment and medicines. However, the practice did not have the full range of clear face mask sizes required under national guidance. We also found that Buccal Midazolam, an emergency medicine used to treat prolonged seizures, was not stored in accordance with the manufacturer’s instructions. We saw logs of internal checks of the emergency equipment and medicines dating back to March 2026. Prior to this, checks were not consistently recorded, and logs did not always include expiry dates to indicate when medicines or equipment required replacement. This meant we could not be assured that systems for managing emergency medicines and equipment were fully effective. Following the inspection, we received confirmation that the missing items had been ordered.

Staff 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 did not see satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Although an electrical safety inspection had been completed shortly before the inspection, the practice had not received the report and was unable to provide evidence of any previous inspection. We received the report after the inspection, and it was marked unsatisfactory and indicated that dangerous conditions had been identified. This meant we could not be assured that the practice had effective arrangements in place to ensure equipment was safe to use. We will follow up to ensure appropriate action has been taken to address these concerns.

A gas safety inspection had been carried out in the days following the announcement of our inspection. Prior to this, the most recent inspection was carried out in 2023.

The compressor was serviced in the days following the announcement of our inspection. Prior to this, it had last been serviced in 2022.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

Fire safety was not managed effectively. Fire extinguishers had only been serviced following notification of our inspection. Prior to this, they had last been serviced in 2022. In addition, the smoke alarms had not been serviced since 2022, meaning the provider could not demonstrate that appropriate fire safety equipment had been maintained in accordance with recommended servicing intervals.

A fire risk assessment highlighted several high risk and medium risk actions. High risk actions are classed as “urgent and important actions and directly relate to loss of control and exposure to unacceptable levels of risk.” We will be following up with the provider to ensure the necessary improvements have been made.

The provider told us they were unsure how to test the smoke alarms, and that weekly internal tests were not conducted.

The practice had systems for appropriate and safe management of medicines. However, there was no log in place to track and monitor stock. The provider assured us this would be implemented.

Recruitment procedures required improvement to ensure accurate, complete and detailed records are maintained for all staff, and that appropriate checks are completed prior to new staff commencing employment at the practice to reflect the relevant legislation. The recruitment policy was in line with relevant legislation; however, it was not consistently adhered to.

References were not routinely documented. Disclosure and Barring Service (DBS) checks were not always carried out at the time of employment contrary to the policy. In some cases, staff began work prior to the checks being completed without a risk assessment in place to mitigate this risk. At the time of inspection, 1 member of staff did not have DBS check. The provider confirmed a check had been applied for and was pending.

Right to Work checks were not always conducted at the time of recruitment.

In addition, Hepatitis B titre levels (to indicate immunity) had not been obtained for 2 clinical staff members. The provider assured us that blood tests would be booked in to obtain this information.

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 ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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 received appropriate training and 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 some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. A Legionella risk assessment had been carried out the week before our inspection. It highlighted a number of actions and procedures that needed implementing such as flushing lesser used outlets and recording water temperatures monthly to ensure they are reaching the required temperatures.

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 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.