Globe Dental Practice

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• 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.

Staff knew how to respond to a medical emergency and most staff had completed training in emergency resuscitation and basic life support every year. We noted there was no evidence 1 member of staff had completed their annual medical emergencies training.

Staff we spoke with told us that equipment and instruments were well maintained and readily available.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. However, we observed the provider was not carrying out daily temperature checks of the fridge where they stored the Glucagon, a medicine used to treat severe hypoglycaemia (low blood sugar). The provider has submitted evidence following the assessment they are now carrying out daily fridge temperature checks.

The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions.

Fire exits were clear and well signposted, and fire extinguishers were serviced annually.

A fire safety risk assessment was carried out in line with the legal requirements. However, the management of fire safety was not effective. The practice did not conduct in-house fire equipment checks in line with the risk assessment, and we observed on the day that the smoke alarms did not appear to be working and highlighted this to the provider. There was no evidence the emergency lighting had undergone its annual duration test or service. The practice submitted evidence following the assessment that in-house fire testing has now begun. We were assured by the immediate response that the risk to safety was mitigated. Improvements must be made to ensure better governance of fire safety.

The practice had ineffective arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. This included cone-beam computed tomography (CBCT). We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings. Improvements were required to the practice’s governance processes to maintain oversight of radiation protection. In particular, ensuring all intra-oral X-ray machines undergo 3-yearly routine performance testing and ensuring recommendations from critical examination reports are addressed in a timely manner. The practice submitted evidence following the assessment that the 3-yearly routine performance testing for the intra-oral X-ray machines had been booked for 26 February 2025.

The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. However, improvements were required to ensure the staff knew where these were stored.

The practice had implemented some systems to assess, monitor and manage risks to patient and staff safety. However, improvements were required to ensure an up-to-date sharps safety risk assessment was conducted and reflective of the practice protocols, and to ensure that sharps injuries posters were displayed in all clinical areas. We also noted a health and safety risk assessment from 27 July 2021 had outstanding recommendations. The practice submitted evidence that an up-to-date sharps risk assessment had been conducted following the assessment.

The practice had some systems for appropriate and safe management of medicines. NHS prescription pads were kept secure. However, improvements were required to ensure there was a pre-populated log in place to monitor and track their use.

Staff we spoke with had the skills, knowledge and experience to carry out their roles.

Staff discussed their training needs during appraisals, practice team meetings and ongoing informal discussions.

The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. However, these were not followed. We noted references were not sought for 4 staff members and Disclosure and Barring Service (DBS) checks were not conducted or risk assessed at the time of recruitment for 7 staff members. There was no evidence of Hepatitis B titre levels (to indicate the immunity levels against the virus) for 3 staff members. Checks were not always carried out to ensure clinical staff were General Dental Council (GDC) registered and there was evidence of a clinical staff member assisting for dental treatments who was no longer on the GDC register. Improvements must be made to ensure better oversight of all recruitment in line with legislation. There was no evidence of any recruitment records other than a curriculum vitae (CV) for a recent new starter who had commenced work at the practice.

Improvements were required to the systems for ensuring staff training was up-to-date and reviewed at the required intervals. We noted 3 clinical staff members had not completed their safeguarding level 2 training, and 2 administrative staff members had not completed their safeguarding level 1 training within the last 3 years. We noted there was no evidence that staff members had undergone their periodic fire awareness training. Following the assessment, we received evidence 2 members of staff have completed their safeguarding level 2 training and that a fire awareness and fire marshal course had been booked for all staff. We were not assured there was effective support in place for new starters. There was no evidence new starters had received a role specific induction and that their training and learning needs had been assessed.

The practice had infection control procedures that reflected published guidance.



Staff demonstrated knowledge and awareness of infection prevention and control processes.



We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance. We saw, and staff confirmed that single-use items were not reprocessed. We noted the heavy-duty gloves, used in the decontamination process of reusable dental instruments, were not changed weekly in line with guidance. We raised this with staff and were assured this would be addressed and rectified.



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



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



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

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