Archived: Pennine Dental and Medical Care

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.

The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspection on 14 November 2025. We have told the provider to take action. We will be following up on our concerns to ensure the provider has made the required improvements.

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 did not have effective systems to identify and manage risks.

Not all medical emergency medicines and equipment were available in accordance with the Resuscitation Council (UK) guidance.

During the inspection on 14 November 2025, we found that the practice did not have adult and child self-inflating bags with reservoirs or clear face masks for use with the self-inflating bags. In addition, oropharyngeal airways and syringes required for the administration of Adrenaline (a medication used to treat a severe allergic reaction) and Midazolam (a medication used to treat prolonged epileptic seizures) were not available. The practice did not have paediatric pads for the Automated External Defibrillator (AED), a mercury spillage kit or a bodily fluid spillage kit. We also found that the weekly medical emergency checks undertaken to confirm the availability of required medical emergency medication did not accurately reflect the medical emergency drugs available between January 2025 and November 2025.

Furthermore, we identified concerns regarding the storage of Glucagon, a medicine used to treat severe hypoglycaemia, to ensure it was maintained within the manufacturer’s recommended temperature range.

In the provider’s action plan dated 19 November 2025, they set out the steps they proposed to take to address the concerns identified regarding the management of medical emergencies. These included adding syringes to the emergency drugs kit and purchasing a full airway set, child and adult self-inflating bags, mercury and bodily fluid spillage kits and paediatric AED pads within 7 days and commencing daily fridge temperature logs within 48 hours.

On 11 February 2026, we requested supporting documentary evidence to demonstrate the improvements made following our inspection on 14 November 2025. No information, documentation, or evidence was provided in response to this request to substantiate the improvements the provider had implemented to the management of medical emergencies.

During the follow-up inspection on 13 February 2026, staff told us that, to their knowledge, fridge temperature monitoring had been paused by the provider. On inspection of the medical emergency equipment, we found that the items identified as missing on 14 November 2025 were still absent. In addition, although Glucagon was stored in the fridge, the fridge temperature was 1°C, which is below the temperature range recommended by the manufacturer. The staff member present was unable to provide any information about the improvements implemented since the inspection on 14 November 2025 in relation to the management of medical emergencies.

During the inspection on 14 November 2025, we found that the provider had not ensured that staff were competent in dealing with medical emergencies. The provider, who was the only clinician working at the practice, did not demonstrate adequate competence in dealing with medical emergencies. Furthermore, there were no records to demonstrate that they had consistently completed annual training in emergency resuscitation and basic life support.

In the provider’s action plan dated 19 November 2025, they set out the steps they proposed to take to address the concerns identified regarding staff knowledge and competency in the management of medical emergencies. This included arranging face-to-face basic life support and AED training for the dental team on 20 November 2025.

On 11 February 2026, we requested supporting documentary evidence to demonstrate the improvements made following our inspection on 14 November 2025. No information, documentation, or evidence was provided in response to this request, including training completion evidenced by certificates.

During the follow-up inspection on 13 February 2026, staff told us that, they were not aware if the face-to-face basic life support and AED training took place on 20 November 2025. It was their understanding that this training is scheduled for 25 February 2026. The staff member present further told us that, although they completed First Aid training 2 years ago, they had not undertaken basic life support and AED training and would not know how to identify or use oxygen or other medical emergency equipment within a dental setting.

Overall, we were unable to obtain reassurance that the risk levels identified on 14 November 2025 in relation to the management of medical emergencies had been reduced.

During the inspection on 14 November 2025, we found that the practice did not have effective systems in place for the safe use of radiography equipment. Whilst we do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017, we request services to provide evidence that demonstrates their compliance to inform our findings. At the time of the inspection, the provider had not appointed a Radiation Protection Advisor (RPA) and was not aware of the requirement to do so or of who could fulfil this role. We saw no record that the installation examination and/or subsequent performance checks had been carried out for the intraoral X-Ray unit. In addition, there were no historical servicing records to demonstrate that effective systems were in place to ensure the X-Ray unit was safe to use. Furthermore, the provider could not demonstrate that employer’s procedures and an appropriate risk assessment were in place for the use of radiographic equipment.

In the provider’s action plan dated 19 November 2025. they set out the steps to address the concerns identified in relation to radiation safety. These included appointing an RPA, booking a service engineer for full testing of the intraoral X-Ray unit, enrolling on a Radiation Protection Supervisor (RPS) course, and drafting and implementing employer procedures.

On 11 February 2026, we requested supporting documentary evidence to demonstrate the improvements made following our inspection on 14 November 2025. No information, documentation, or evidence was provided in response to this request, including evidence of actions taken to improve radiation safety.

During the follow-up inspection on 13 February 2026, the staff member present was unable to provide any information or assurance regarding improvements to the safe management of radiographic equipment.

Overall, we were unable to obtain reassurance that the risks identified on 14 November 2025 in relation to radiation safety had been reduced.

During the inspection on 14 November 2025, we found that the management of Control of Substances Hazardous to Health (COSHH) was ineffective. Not all hazardous substances used by the practice had been risk assessed, and safety data sheets were not accessible to staff. We did not receive any documentary evidence following the inspection to demonstrate that appropriate action had been taken to improve the management of hazardous substances. During the follow-up inspection on 13 February 2026, we were unable to obtain sufficient assurance that the risks previously identified in relation to COSHH management had been reduced.

The management of fire safety was not effective. During the inspection on 14 November 2025, we were provided with an undated fire risk assessment. However, this had not been completed by a person who had the qualifications, skills, competence and experience to do so.

There were no records to show that fire evacuation drills had been carried out. In addition, weekly in-house testing records for the 2 battery-operated smoke detectors were not available. We also observed that 2 of the fire exits identified in the fire risk assessment were locked and obstructed by metal shutters, making them inaccessible as escape routes. Signage indicating these as fire exits was misleading. There was no evidence of servicing for the fire extinguishers, 1 of which had a disconnected hose, which could render the equipment inoperable when needed.

In the provider’s action plan dated 19 November 2025, they set out the steps to address the concerns identified in relation to fire safety. These included commissioning a fire assessor, obtaining quotes for the servicing of the fire extinguishers, commencing periodic in-house checks, carrying out a fire evacuation drill and removing the fire exit signage from the rear doors.

On 11 February 2026, we requested supporting documentary evidence to demonstrate the improvements made following our inspection on 14 November 2025. No information, documentation, or evidence was provided in response to this request, including evidence of actions taken to improve fire safety.

During the follow up inspection on 13 February 2026, the staff member present told us that someone had attended the premises to assess fire safety. However, they were unable to provide any further information or evidence regarding improvements implemented to mitigate fire risks.

Overall, we were unable to obtain assurance that the risks identified on 14 November 2025 in relation to fire safety had been reduced.

During the inspection on 14 November 2025, we found that the practice had not ensured that the facilities were maintained in accordance with regulations. There were no records to demonstrate that electrical installation condition report (EICR) checks had been carried out to assess the safety and integrity of the fixed electrical systems. We did not receive any documentary evidence following the inspection to demonstrate that appropriate action had been taken to address this concern. During the follow-up inspection on 13 February 2026, we were unable to obtain assurance that the risks previously identified in relation to the safety of the premises had been reduced.

During the inspection on 14 November 2025, we found that the practice did not have suitable and robust recruitment procedures in place. We did not receive any documentary evidence following the inspection to demonstrate that appropriate action had been taken to review and strengthen recruitment processes, including the implementation of safer recruitment checks. During the follow-up inspection on 13 February 2026, we were unable to obtain assurance that the provider had taken any steps to improve and embed robust recruitment procedures.

During the inspection on 14 November 2025, we found that the practice did not have effective systems in place to ensure staff training was up-to-date and reviewed at the required intervals.

Whilst we saw some training certificates completed after the announcement of that inspection, historical records were not available to demonstrate continuous professional development had been consistently maintained. Additionally, the provider could not demonstrate that all staff completed training in the safeguarding of children and vulnerable adults at a level appropriate to their role, fire safety, mental capacity, learning disability and autism awareness or, where required, radiography. Overall, we were not assured that the systems in place to support staff learning, training, and development were effective in enabling them to fulfil the requirements of their role.

Following the inspection on 14 November 2025, the provider told us that core training, including safeguarding, radiation safety, fire safety and autism and learning disability would be arranged for staff. However, we did not receive any documentary evidence to demonstrate that staff had completed training in these core topics or that effective systems had been implemented to monitor and manage training requirements. During the follow-up inspection on 13 February 2026, the staff member present provided evidence of having completed Level 2 training in Safeguarding Children and Vulnerable Adults. However, no other training certificates were available for review. As a result, we were unable to obtain assurance that the previously identified risks in relation to staff training, knowledge and competency had been reduced.

During the inspection on 14 November 2025, we found that the practice infection control procedures did not reflect published guidance. We observed the decontamination of used dental instruments, which did not align with national guidance. We saw that staff did not carry out handwashing before or after performing the decontamination process. Staff did not wear the appropriate Personal Protective Equipment (PPE) including mask, visor and apron for the decontamination process. Instruments were not fully immersed during scrubbing, and a thermometer was not used to ensure water used for manual cleaning was under 45°C as required.

Systems and processes to ensure cleaned instruments were free from visible contamination were not effective. We saw dental cement residue on some of the instruments staff told us had been disinfected and cleaned.

There were no records showing that weekly autoclave tests were being done. The decontamination room did not have a clear dirty‑to‑clean workflow or a suitable place for sterilised instrument trays. Staff were also washing mugs and cutlery in the same sink used for contaminated dental instruments, meaning the practice had not recognised or managed the risk of cross‑contamination.

The provider was the decontamination lead, and we identified gaps in their knowledge of infection prevention and control. This meant that they were not competent to identify issues with the decontamination process.

In the provider’s action plan dated 19 November 2025, they set out the steps they intended to take to address the concerns related to infection prevention control. These included arranging training for staff to ensure PPE was always available and worn, carrying out weekly tests on the autoclave, displaying signage to separate the decontamination process from other activities and introducing a colour coded cleaning system. However, we did not receive any documentary evidence to demonstrate that these actions had been completed. During the follow-up inspection on 13 February 2026, the staff member present was unable to provide any information about the improvements made in relation the management of infection prevention and control. As a result, we were unable to obtain assurance that the previously identified risks in relation to infection prevention and control had been reduced.

During the inspection on 14 November 2025, we found that the management of Legionella and other bacteria developing in the waterlines was not effective. Recommendations made in the Legionella risk assessment dated 23 September 2025, and carried out after the inspection announcement, had not been actioned. These actions included: correcting the installation of expansion vessels by fitting drain valves and incorporating them into flushing/inspection regimes; removing redundant pipework; descaling and disinfecting outlets; implementing a formal written scheme of control; undertaking routine temperature monitoring; establishing remedial protocols and ensuring that all staff with responsibility for Legionella management have completed the required training. Additionally, there were no records of previous Legionella risk assessments to demonstrate that the practice had systems in place for the ongoing management of Legionella-related risks or for the regular review of past assessments.

Following the inspection on 14 November 2025, the provider told us that they would ‘go through’ the risk assessment dated 23 September 2025. However, the provider did not specify the actions they would take to act on the recommendations made in the report.

During the follow-up inspection on 13 February 2026, the staff member present told us that to their knowledge, water temperature monitoring had been paused by the provider. They were unable to provide further information about the improvements made in relation the to the management of Legionella and other bacteria developing in the water systems. As a result, we were unable to obtain assurance that the previously identified risks been reduced.

During the inspection on 14 November 2025, we found that the infection prevention and control audit dated 29 August 2025 was not reflective of our findings on the day. For example, it failed to identify several issues observed during the visit, including instruments not being fully submerged during scrubbing, the absence of alcohol-based hand rub, a lack of weekly testing of the autoclave, no clear dirty to clean flow during the decontamination process and inappropriate PPE use. Previous audits were not available for review. Following the inspection on 14 November 2025, the provider told us that they would carry out a robust infection prevention and control audit. However, the revised audit was not submitted in response to our subsequent information request and was not made available during the follow-up inspection on 13 February 2026. As a result, we were unable to obtain assurance that effective auditing and oversight arrangements had been established to identify and address infection prevention and control risks.

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