Coventry Road Dentalcare

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.

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 processes to identify and manage risks, although at the time of assessment we identified that there was no legionella risk assessment available for review. Evidence of a newly completed legionella risk assessment was sent following this assessment. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice, and this was reflected in our findings.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Staff providing treatment to patients under sedation had also completed immediate life support training (or basic life support training plus patient assessment, airway management techniques and automated external defibrillator training).

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

Records were available to demonstrate appropriate servicing and validation of equipment in line with manufacturer’s instructions. However, issues had been identified with the radiography equipment in 3 treatment rooms during the critical examination check completed in 2023. The provider confirmed that these issues had not been addressed but assured us that action would be taken immediately. An engineer was contacted during the assessment to address the issue in one of the treatment rooms and action was taken to address the issue identified in the third treatment room. We were assured that the radiography equipment in the other treatment room would be decommissioned immediately. Following this assessment we received evidence to demonstrate that new radiography equipment had been purchased to replace that which was decommissioned.

There was scope for improvement in the management of fire safety. The fire safety checklists we reviewed did not include fire extinguisher, fire escape route or fire door checks. There was no fire exit directional signage on the first floor of the dental practice or anywhere in the separate management building. Action was taken to address issues during this assessment, for example fire exit directional signs were put in place and we were assured that a log of fire exits, doors and fire extinguishers checks would be introduced immediately. Following this assessment we received confirmation that a new logbook had been implemented and staff training completed in its use.

We saw a copy of the fire risk assessment completed by an external professional. We were not provided with assurances that all issues identified had been addressed relating to the management building. We were however assured that issues relating to the dental practice had been addressed.

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, to help them employ suitable staff, including agency or locum staff.

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

Newly appointed staff had an appropriate role specific structured induction.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of 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 practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. A new system was being introduced which gave the practice manager easier access to staff training records which enabled better monitoring and support if required.

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 annual appraisals, clinical supervision, practice team meetings and ongoing informal discussions.

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

The practice had infection control procedures that reflected published guidance. We identified some issues for action on the day of assessment which we discussed with the provider.

There was a small tear in the operator chair in surgery 1.

There were no cleaning schedules or logs for the general cleaning of the practice. Following this assessment we received confirmation that the practice has introduced a surgery cleaning schedule and a practice environmental cleaning record.

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.

There was scope for improvement in the practice’s systems to reduce the risk of Legionella, or other bacteria, developing in water systems. We were told a legionella risk assessment had been completed in 2013 but this was not available on the day of assessment. A further risk assessment had not been completed when there had been changes at the practice such as adding dental chairs and extending the practice. Following this assessment we received a copy of a legionella risk assessment completed on 5 March 2025 and were told that all issues identified would be acted upon.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. Although clinical waste was stored behind a locked gate, we saw that one clinical waste bin was broken and bags were easily visible and accessible. We discussed this with the provider who confirmed that for absolute security a new bin would be obtained. Following this assessment we received confirmation that a new clinical waste bin had been ordered.

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.