Night and Day Emergency Dentist

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.

Although 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.

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 equipment in line with manufacturer’s instructions.

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

The practice managed fire safety well, and fire exits were clear and well signposted.

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

However, the provider’s systems and processes of oversight to identify, monitor and manage risks relating to the service were ineffective and required improvements. They had not completed a health and safety risk assessment, risks associated with sharps were not appropriately risk assessed or managed and environmental cleaning logs were not completed consistently.

In addition, the lone working and whistleblowing policies available on the inspection day contained information for another practice and did not reflect local protocols. The provider submitted new lone working and whistleblowing policies after the inspection.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, these were not always followed.

We reviewed 7 recruitment files on 23 June 2026 and additional evidence on 26 June 2026. We found gaps in recruitment records, including missing or expired evidence of General Dental Council (GDC) registration, professional indemnity cover, Hepatitis B immunity, Disclosure and Barring Service (DBS) checks, and satisfactory conduct in previous employment. We also identified that one staff member undertaking a clinical role had not received the appropriate level of DBS check prior to employment.

The practice had ineffective systems and processes of oversight for staff training. As a result, they were unable to ensure staff training was up-to-date, completed at the appropriate level and reviewed at the required intervals.

The practice could not demonstrate clinical staff had completed Continued Professional Development (CPD) as required for their registration with the GDC. On the day of inspection, we checked 7 recruitment files. Training certificates for medical emergencies, Ionising Radiation (Medical Exposure) Regulations (IR(ME)R), radiography, safeguarding, fire safety awareness and learning disability and autism awareness training, were not available for 6 members of staff.

The practice had infection control procedures (IPC) that reflected published guidance.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. Staff confirmed that single-use items were not reprocessed.

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

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

However, we found systems of oversight and documentation to support IPC procedures required improvement.The findings on inspection showed agreed processes were not always followed.

The IPC policies and procedures had not been reviewed regularly and were not reflective of our findings on the day of the inspection. We saw a cleaning mop stored inappropriately in the decontamination area. There was no documented evidence to demonstrate completion of daily surgery checks or daily decontamination room checks. Hazardous waste consignment notes, a legal document required to track hazardous waste from its producer to its final disposal, were also missing.

In addition, oversight of procedures to reduce the risk of Legionella or other bacteria developing in water systems were ineffective. A Legionella risk assessment had been carried out on 21 October 2025, but the provider could not demonstrate on the day of inspection that recommendations made within the risk assessment had been actioned. They since submitted evidence to show these actions had been addressed. Documentation to demonstrate staff were completing hot and cold-water temperature checks in line with recommendations was also not available on, nor submitted after the inspection day.

The practice completed IPC audits in line with current guidance. However, these audits were not providing sufficient oversight or opportunity to improve practice. The last audit in June 2026 failed to identify the issues we found on the inspection day or highlight the required improvements to governance and documentation.

The provider submitted daily surgery checklists and a new IPC policy after the inspection. However, we could not be assured of the surgery checklists’ accuracy as these contained completed records for dates in the future and the new IPC policy did not reflect the protocols at the practice. Some hazardous waste consignments notes were also submitted after the inspection. However, there were only two available for 2021 and three for 2026. We did not see any consignment notes between May 2021 and April 2026.

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