Dental Excellence

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.

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 the availability of emergency equipment and medicines required improvement to ensure national guidance was followed.

We were unable to establish the size and expiry date of one clear mask as it was not stored in its original packaging. A size 3 clear face mask was not available. We have since received evidence to confirm that these shortfalls have been addressed.

The premises were visibly clean, well maintained, and public areas were free from clutter.

Hazardous substances were clearly labelled and stored safely. Control of substances hazardous to health (COSHH) risk assessment and safety data sheets were available for every COSHH applicable substance used at the practice.

The practice had processes to identify and manage risks, but improvement was needed. Current three yearly performance test certificate was not available for 3 X-ray machines. We were provided with evidence to confirm that an engineer was booked to attend on 31 March 2025. Evidence of a 3 yearly quality performance test for the CBCT machine was not available. A fire risk assessment was carried out in line with the legal requirements. The management of fire safety was ineffective. The fire alarm manual call points tests were not carried out in rotation. We have since received evidence to confirm that this shortfall has been addressed. We were told that monthly emergency lighting tests were carried out, Improvements could be made to record the location of the emergency lights to ensure none are missed during testing.

Staff stated they felt respected, supported, and valued, and they were proud to work in the practice.
They told us that there were sufficient staffing levels.
Staff knew their responsibilities for safeguarding adults and children.
The practice ensured clinical staff were registered with the General Dental Council.
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 ongoing informal discussions.
Evidence to confirm that appraisals were carried out for all staff were available.
The practice had a recruitment policy and procedure to help them employ suitable staff in accordance with relevant legislation.
The practice had systems in place to ensure all staff had completed training as per recommended national guidance,

Annual basic life support training was overdue for one member of staff. We were provided with evidence to confirm that training has since taken place.

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

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

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment.

We noted that the external clinical waste bins were not tethered to a fixed point to prevent unauthorised removal.

Staff uniforms and outdoor clothes stored in lockers. These were not separated to prevent the risk of cross contamination.

An annual infection prevention and control statement was not available.

The floor seal under the cabinetry in treatment room 3 was not complete and impervious.

Un-pouched x-ray film positioners were stored in treatment room drawers.

Haemostatic sponges (dressings) that had been broken down from their original packaging did not have their expiry date transferred to the current container.

We have since received evidence to confirm that these shortfalls have been addressed.

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