JH 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 they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low.

During our assessment of this key question, we found concerns related to the safety of the premises, recruitment, and training, support and development of staff, and the infection prevention and control standards being followed at the practice.

This resulted in a breach of Regulations 12, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings below. Whilst there are issues to be addressed, the impact of our concerns relate to the governance and the oversight of the risks, rather than a patient safety risk.

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.

There was scope for improvement in the practice’s processes to identify and manage risks.

One item of emergency equipment was out of date, the provider assured us that replacement equipment would be ordered immediately. All other emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Not all staff had completed training in emergency resuscitation and basic life support every year. Following this assessment we received evidence to demonstrate that 3 staff had completed online basic life support training and another clinician had completed face to face basic life support training. This training was outstanding for 1 newly appointed staff member.

The premises were visibly clean, although there were no cleaning schedules or logs to demonstrate cleaning undertaken. Some areas contained out of date personal protective equipment which was awaiting disposal. Hazardous substances were clearly labelled and stored safely. There were no safety data sheets for hazardous products in use at the practice. Following this assessment we received evidence of newly implemented and completed daily and weekly cleaning logs. We saw a random sample of safety data sheets and were assured that these were available for each product in use at the practice.

There were no records to demonstrate the servicing and validation of the ultrasonic cleaner. The provider confirmed that the compressor was overdue for service and stated this would be completed within the next few weeks. Records were not available to demonstrate that electromechanical servicing had been undertaken on X-ray machinery and there were no records of the 3-year performance check for the X-ray machinery in one of the treatment rooms. Rectangular collimators were not available on X-ray sets. Following this assessment we received evidence of validation of the ultrasonic cleaner. We also saw evidence that rectangular collimators were in place on X-ray sets.

There was scope for improvement regarding the management of fire safety. There was no fire risk assessment. Records available demonstrated that fire extinguishers were serviced and checked as required. There were no records to demonstrate that smoke alarms or fire exits were regularly checked. Not all staff had completed fire safety training. There was no evidence of any personal emergency evacuation plans or alternative arrangements as the practice did not have emergency lighting or a fire alarm. There was no documented evidence of regular fire drills. Other records such as five-year fixed wiring test certificates and gas safety certificates were not available. Fire exits were clear and well signposted. Following this assessment the provider sent evidence of a fire drill log which was to be implemented, along with a log to demonstrate that smoke alarms were to be tested. There was also a proforma for staff training in fire safety. We received confirmation that the provider had booked an external company to conduct a fire risk assessment on 13 March 2025 and we were sent a copy of a recently completed gas safety check.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, although recruitment records seen did not demonstrate that the practice were working in accordance with this policy.

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

There was limited evidence to demonstrate that newly appointed staff had an appropriate role specific structured induction.

Staff we spoke with had the skills and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times. There was scope for improvement in staff’s knowledge of safeguarding. There was no evidence to demonstrate that all staff had completed safeguarding training to the required level. Staff were unsure about ‘was not bought’ where a child was not bought to their appointment and its relevance to safeguarding. Staff were aware of how safeguarding information could be accessed but this was not freely available throughout the practice. Staff knew how to escalate safeguarding concerns within the practice. Following this assessment we received evidence that a further 2 staff had completed or partially completed safeguarding level 2 training.

There was scope for improvement in the practice’s arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Following this assessment we were sent some evidence to demonstrate that further training had been completed as detailed above. Evidence was still outstanding to demonstrate that all staff had completed the required learning.

There was no written evidence to demonstrate that staff formally discussed their training needs and aims for future professional development.

Staff stated they felt respected and valued and they were proud to work in the practice. Staff praised the management saying that they were caring and supportive.

There was limited oversight of infection prevention and control for example;

There was an aid memoir for the ‘opening and closing’ of the dental surgery each day, this was on display in the office/staff room. A recently introduced surgery cleaning log to demonstrate tasks completed at the start of each session, in between patients and at the end of each session was sent to us following this assessment.

Local anaesthetic was not being stored in blister packs in surgeries.

There were no service or maintenance records for the ultrasonic cleaner in use (no soil/protein tests). Newly implemented maintenance records were forwarded following this assessment.

There was no blood or bodily fluids spill kits available. These were ordered following this assessment.

Evidence was available to demonstrate that some staff received appropriate training and 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. Instruments were pouched after sterilisation but pouches were not dated.

There was scope for improvement to ensure that the practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. There was no legionella risk assessment in accordance with guidance.

The practice had protocols to ensure safe segregation and disposal of hazardous waste. There were no cleaning schedules or logs in place to demonstrate effective cleaning of the practice. There was no information on display regarding the correct colour coded cleaning equipment to be used in the appropriate area. Staff were not aware of the correct colour coded equipment to use in the treatment room. Following this assessment we received confirmation that the provider had put in place posters demonstrating the correct colour coding of cleaning equipment and that daily and weekly cleaning logs had been implemented.

The equipment in use was maintained and serviced as per manufacturers’ instructions. The compressor was overdue for routine service, the provider was aware and confirmed that this would be completed as soon as possible.

The practice completed infection prevention and control audits in line with current guidance. The audit we saw identified some issues for action which had not been addressed, these were also identified during this assessment.

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