St Mark Dental Surgery

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. During our assessment of this key question, we found concerns related to the following 1. Failure to ensure that the premises and equipment were safe to use for the intended purpose which resulted in a breach of Regulation 12; 2. Failure to ensure that persons employed in the provision of a regulated activity received appropriate support, training, professional development, supervision and appraisal as was necessary to enable them to carry out the duties they were employed to perform. This resulted in a breach of Regulation 18; 3. Failure to ensure that all the information specified in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was available for each person employed. This resulted in a breach of Regulation 19; 4. Failure to protect staff and patients against the risk of Hepatitis B virus which resulted in a breach of regulation 19 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.

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 we spoke with did not know how to respond to a medical emergency. We were told that some staff had completed online training in emergency resuscitation and basic life support, yet we were not shown evidence for all staff members. Staff told us that medical emergency training had been booked for a few weeks’ time, however we did not see evidence to confirm this. In addition, staff did not carry out any medical emergency scenario training. The service advertised that they provided sedation services. We raised this with the provider who told us that this service was not currently being provided. We also noted that the provider and those involved in sedation had not completed mandatory training in Immediate Life Support. If the practice does decide to provide treatment under conscious sedation, all members of the sedation team should have current immediate life support training in place in line with guidance. Emergency equipment and medicines were available, and the practice told us they were checked in accordance with national guidance. On the day of the inspection, we noted that the ‘non-expired’ emergency medicines were still in an unopened container. This was raised with the practice who told us that they had recently ordered items to replace the existing medicines which had expired. At the end of the inspection, and after the inspection team opened the box, the provider showed us a weekly checklist. It was unclear how these items could have been checked previously as the container had been sealed. It was, therefore, not demonstrable that the practice had an effective system in place to ensure emergency medicines remained in date and fit for their intended purpose. We saw that the Electrical Installation Condition Report (EICR) and the Portable Appliance Testing (PAT) had both been carried out after the announcement of this inspection.

The practice was not able to provide us with records to confirm that the gas boiler had received servicing in line with manufacturer’s guidance and legislation. The gas boiler was due for a safety check in September 2023; hence this was significantly overdue. The last safety check, which was completed in October 2022, highlighted that the gas boiler was in poor condition and recommended replacing, however at the time of the inspection this was still not rectified. The practice was unable to provide certification for the annual service for the autoclave (a machine that uses steam under pressure to kill harmful bacteria, viruses, fungi, and spores on items that are placed inside a pressure vessel). Daily tests were, however, being carried out and documented. A fire safety risk assessment was carried out after the announcement of this inspection. There were multiple actions required, including a high priority action (arrange immediately and complete within 7 days). There was no action plan outlining how and when these actions would be completed. Staff had not received training in fire safety nor were there nominated fire marshals and we saw no records to confirm that they carried out routine evacuation drills. We saw that the fire alarms and the emergency lighting system had been serviced after the announcement of this inspection. The servicing reports highlighted several issues, including multiple fire alarms and emergency lights not working. The previous service was in 2018 and 2019 respectively. The fire alarms and emergency lights were not being routinely tested and maintained by the practice according to regulations. There were fire extinguishers, however, we were not provided with evidence to confirm these were routinely inspected and serviced. Therefore, the management of fire safety was ineffective. The Employer’s Liability Insurance Certificate was not displayed as required by government legislation.

The practice did not have arrangements to ensure the safety of the X-ray equipment. The practice had not appointed a Radiation Protection Advisor (RPA) or Medical Physics Expert (MPE) which was required to be compliant with Ionising Radiations Regulations 2017. New intra-oral radiograph units had been fitted in 2022, and the critical examinations for 2 units stated that an RPA/MPE must be consulted prior to use. This had not been carried out. Additionally, the practice could not demonstrate that Ionising Radiation (Medical Exposure) Regulations (IR(ME)) training had been completed. The practice was not carrying out any radiograph audits. Following the inspection, we saw that the provider had a new contract with a dental company to provide Radiation Protection Consultancy which started following the inspection. However, this stated that an RPA/MPE will be appointed upon receipt of payment, of which we did not receive evidence. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health, yet we were told that this had not been updated since 2018. We were not given assurance that all hazardous products in the practice had been included. The practice had ineffective systems to assess, monitor and manage risks to patient and staff safety. We saw that a sharps risk assessment had been completed, but this was not reflective of our findings on the day, for example, it stated that “the practice routinely uses safer sharps” and that they “use resheathing devices” yet these were not present in the practice. Additionally, there was no lone worker risk assessment, and we were told that the cleaner works in the practice alone. Antimicrobial prescribing audits were not carried out. Following the inspection, we saw that an audit had been completed; however, improvements were required to ensure that results were summarised and evaluated against national guidance.

We saw that there were 2 trainee dental nurses employed at the practice. We saw no documented evidence that these trainee dental nurses were receiving appropriate support, training and supervision at the practice by a named registrant with the General Dental Council. Staff told us they discussed their training needs in informal discussions. We were not provided with evidence of staff appraisals, despite being informed prior to the inspection by the provider, that these were being carried out. Whilst staff demonstrated knowledge of safeguarding, we found that improvements were needed to ensure all staff received training appropriate to their role. On the day of the inspection, we saw evidence of training for 1 staff member only. The safeguarding policy was updated in September 2024, and was obsolete as it contained out of date information. Other pertinent safeguarding information was missing from the policy and was not available around the practice. It was therefore unclear how safeguarding information could be accessed. The practice did not provide any evidence of staff training for any staff members for Infection Prevention and Control, Fire safety or Learning disability and autism. We saw that some staff members had training in Basic Life Support (online) and 1 staff member had evidence of safeguarding training. The practice did not have arrangements to ensure staff training was up-to-date and reviewed at the required intervals.

The practice had a recruitment policy and procedure to help them employ suitable staff, but this was not being followed. For example, we saw that Disclosure and Barring Service (DBS) certificates were present for only 6 staff members. Whilst we saw applications had been completed for 2 staff members, these were submitted after the announcement of the inspection. A risk assessment for not having a DBS certificate was present for 2 staff members; however, the practice name was incorrect in both, and one was dated November 2025. Satisfactory evidence of conduct in previous employment was not present for 9 staff members, including staff who had been recently recruited. Proof of identification was present for only 4 staff members. Satisfactory verification of the reason why the person’s employment in a position relating to work involving children or vulnerable adults ended had not been obtained for any staff members. Satisfactory evidence of qualifications relevant to the duties for which the person is employed had been obtained for only 1 staff member. A full employment history had not been obtained for any staff members. Satisfactory information about any physical or mental health condition which are relevant to the person’s capability to properly perform tasks had not been obtained for any staff members. We did not see evidence of an induction for any staff members. Additionally, there was no evidence of immunisation status for Hepatitis B for 6 members of staff and there were no associated risk assessments to mitigate the risks of unknown immunity to Hepatitis B.

The practice appeared clean, however there was no schedule in place to ensure effectiveness of cleaning. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Staff demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. The practice completed infection prevention and control (IPC) audits; however these were not in line with current guidance as they were completed annually instead of bi-annually. We did not see evidence of any training for any staff members in IPC. The practice had updated their Legionella risk assessment in January 2022, however we did not have assurance that the person who carried this out had the skills, competence and training to do so. The risk assessment had not been updated since completion of the refurbishment of the practice. Monthly water temperature checks were not being carried out. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. Waste consignment notes were not readily available but were provided following the inspection.

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