Neem Dental Clinic

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:

sharps safety,

safe and effective recruitment of staff,

training, support and development of staff,

adequacy and availability of emergency equipment and medicines,

lack of a learning culture at the practice

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 practice had not identified and managed risks effectively, included sharps safety and sepsis awareness. The provider had not completed a general health and safety risk assessment for the premises.

The sharps risk assessment was not sufficiently detailed and did not accurately reflect practice equipment or working practices. The risk assessment did not include risk management procedures such as staff immunisation to Hepatitis B or ongoing training requirements. There was no contact number on the sharps injury poster to indicate where staff could access treatment in the event of a sharps injury. As a result, staff may not have immediate access to the information required to respond appropriately in the event of an incident.

Sepsis knowledge required improvement, some staff did not have sufficient knowledge of the typical symptoms associated with sepsis.

The provider did not maintain medical emergency medicines and equipment effectively. We found that some emergency equipment was missing and several items were out of date. In addition, emergency medicines were not always stored in accordance with recognised guidance.

Although records showed that regular checks of emergency medicines and equipment were completed, these checks had not identified missing or expired items. We also found that checks of the oxygen cylinder had not been carried out effectively.

Following the inspection, the provider informed us that actions had been taken to replace the missing and expired items.

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 somewhat clean. Staff carried out the cleaning, however schedules only covered clinical areas and did not list non-clinical areas such as the toilet and waiting room. We observed some equipment was dusty. Mops for clinical and non-clinical areas were touching, and some were on the floor, risking cross-contamination.

Hazardous substances were clearly labelled and stored safely.

We saw mostly satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, the Electrical Installation Condition Report (EICR) 12 July 2026. The previous certificate was dated 24 July 2020 and whilst this is normally done every 5 years, the certificate stated that due to the type of installation in the practice, a further test would be required after 3 years.

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

Fire safety management required improvement. Logs of internal checks were not reflective of practice procedures and staff signing the logs were not always the ones completing the checks. Staff told us they checked the emergency lighting, however these were not documented.

Fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines.

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. Right to Work checks were not conducted at the time of recruitment and had been requested just prior to our inspection.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

We did not see evidence of role specific structured inductions for all staff.

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 provider did not have oversight of staff training, including continuing professional development. Not all staff had completed mandatory topics such as learning disability and autism awareness or fire safety awareness.

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 practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. However, there was no measuring cup to ensure the correct ratio of cleaning solution and water were being used when manually scrubbing instruments. There was no log to demonstrate that heavy duty gloves were being changed weekly.

The practice had some effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. However, the Legionella risk assessment from 2020 was completed internally by someone we were not assured had the skills or competence to do so. Since the inspection, the provider has confirmed a risk assessment has been booked.

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.

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.

We saw, and staff confirmed that single-use items were not reprocessed.

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