Exceldent

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.

During our assessment of this key question, we found concerns related to

the safety of the premises and equipment, including medical emergency equipment,

safe and effective staffing,

infection prevention and control standards and

the management of people's medicines.

These concerns resulted in breaches of Regulations 12 (Safe care and treatment) , 17 (Good governance) and 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the report 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.

The practice did not ensure the facilities were maintained in accordance with regulations. There were no records to demonstrate that electrical installation condition and gas safety checks had been carried out. The provider told us it was the landlord’s responsibility to carry out these checks. However, the provider could not demonstrate that they had reassured themselves that these checks had been undertaken to ensure the premises used to provide treatment were safe.

The provider could not demonstrate that they had systems in place to ensure portable appliances were safe to use.

There were no records to show that the principal dentist had completed training in emergency resuscitation and basic life support every year. In addition, the principal dentist often worked alone, which meant they did not ensure they had at least one other person available within the working environment to deal with medical emergencies.

The provider could not demonstrate that the autoclave was validated at installation, nor that it had received annual servicing thereafter in line with the manufacturer’s guidance or in the absence of this, in line with the current guidance.

The practice had not carried out risk assessments of all hazardous substances used within the practice. In addition, staff did not have access to the relevant safety data sheets.

Medical emergency medicines and equipment were not available or in date and were not checked in accordance with national guidance. We further noted that the adult and paediatric pads for the Automated External Defibrillator and single -use syringes had expired, and the practice did not have effective systems in place to ensure the oxygen cylinder was safe to use.

The practice did not have effective systems in place for the safe management of medicines. In the waiting room we saw an expired prescription only medication kept in a glass jar. This was kept in an area easily accessible to patients. In addition, we saw an expired controlled drug kept in the decontamination room on the side of the rinsing sink. This was accessible to staff, including locum staff. We further saw a number of expired dental materials in the treatment room. We could not be assured the practice had effective stock control systems in place to ensure dental materials were not used beyond their expiry date.

The practice did not have a lone worker risk assessment, despite evidence of staff working alone in the practice on a regular basis.

The practice did not have effective systems in place for the safe use of radiography equipment. There were no records to demonstrate that X-ray equipment, were tested and serviced to ensure safe operation, including the orthopantomography (OPG) and the cone-beam computed tomography (CBTC). An OPG machine is a specialised X-Ray machine that captures a panoramic image of the jaws. The CBCT machine takes 3D radiographic images. There were no records to show that installation, three yearly radiological tests or annual electrical and mechanical tests were carried out.

The management of fire safety was not effective. We saw an undated fire risk assessment contained in the practice compliance folder. We were not assured that this was carried out by a person who had the qualifications, skills, competence and experience to do so, as we were not provided records of relevant and appropriate fire awareness training. The risk assessment did not suitably identify the dimension and use of the premises, emergency routes and exits, firefighting equipment, an emergency fire evacuation plan, the needs of vulnerable people and staff training. The last record of in-house fire precaution test was dated 28 February 2010. The sticker on the fire extinguishers located in the corridors indicated that the last service was on 1 July 2016. The provider told us that servicing the fire extinguishers was the landlord’s responsibility and more up-to-date servicing records had not been shared with them. This meant that the provider did not reassure themselves that the fire safety equipment was safe to use. In addition, we saw a large amount of combustible in the decontamination room in close proximity to the autoclave, microwave and the pouching machine all of which produced high heat.

The provider could not demonstrate that they had completed a risk assessment to assess the risks associated with the use of sharps. We did not see that a safer sharps system had been implemented.

The provider failed to ensure they had sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed. On the day of assessment, we saw the principal dentist provided treatment to 3 patients without chairside support. No other support staff were available in the practice. We were told that the principal dentist had worked without chairside support since at least 31 January 2025. The provider told us that they used locum nurses on occasions. However, they were unable to provide evidence to support this.

The practice did not have suitable recruitment procedures in place. There were no records to show that the relevant recruitment checks, including photographic ID, up-to-date Disclosure and Barring Service (DBS) and conduct of evidence in previous employment had been carried out.

The practice did not have effective systems in place to ensure staff training was up-to-date. We did not see evidence of any training for staff. This included evidence of training in safeguarding vulnerable adults and children, medical emergencies, infection control, fire safety, radiography, and interacting with people with a learning disability or autism.

We observed cluttered, dirty surfaces and high levels of dust in the decontamination room and in the treatment room. Due to the clutter in the decontamination room, a dirty to clean flow could not be maintained and there was a risk of contaminated items coming into contact with decontaminated and sterilised instruments. In addition, we were not assured that there was a well-developed and effective routine in place for surface cleaning and decontamination.

There were no systems and processes in place to ensure the separation of instrument reprocessing from other activities by physical or temporal means. We observed a microwave oven, a coffee machine, food items and cutlery in the room used to process contaminated instruments. We were not assured that the provider had identified the risks of surface and aerosol contamination arising from the preparation of food and drinks in the area otherwise used to process dental instruments contaminated with bodily fluids.

There were inadequate infection prevention and control procedures in place in particular with decontamination of dental equipment. We were not assured the provider had effective systems in place to ensure instruments were cleaned as soon as possible after use, to prevent microbial growth. We observed a large number of dental instruments on visibly soiled non-linting cloths in the setting area, next to the rinsing sink. These were in close proximity to contaminated material and in addition, were exposed to cross-contamination arising from aerosol produced when other dental instruments were reprocessed. Overall, we were not assured that the provider had effective systems in place to ensure that instruments were cleaned as soon as possible after use to prevent microbial growth. There were therefore inadequate infection prevention procedures in place to prevent cross-contamination.

Surfaces were not impervious or easily cleanable and walls and floors were not well maintained.

We saw that some single-use or single-patient use items were either decontaminated or sterilised and not disposed of after use.

We observed the decontamination of used dental instruments, which did not align with national guidance. There was no dedicated handwash sink in the decontamination room and 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, including a mask, visor or apron for decontamination process. Systems and processes to ensure cleaned instruments were free from visible contamination were not effective. Staff demonstrated the decontamination process, and we noted that they did not scrub the instruments to ensure cement and bodily fluid residue were effectively removed. We saw cement residue on some of the instruments which went through the autoclave. A thermometer was not used to ensure water used for manual cleaning was within the appropriate temperature range. Staff did not use an illuminated magnifier to inspect instruments for debris. We observed multiple cross-contamination of surfaces during the decontamination process.

Systems to monitor the storage time of sterilised instruments were not effective. We saw that pouches containing sterilised instruments were not dated.

There were no records to show that weekly or daily testing on the autoclave were being completed in line with manufacturer’s instructions or the current guidance.

The practice did not have a Legionella risk assessment or a written waterline management scheme to reduce the risk of Legionella and other bacteria developing in the water systems.

Staff did not have appropriate training, and the practice had not completed infection prevention and control audits in line with current guidance.

However, the practice had procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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