Hot Topics CQC Inspection Trends and Action Plan

April-June 2025

As part of our ongoing work reviewing CQC inspection reports to identify trends and common themes, we have produced this document to highlight what inspectors are looking at and flagging as areas of concern or required improvement. It details the top ten problem topics and the top five associated evidence categories looked at over the last three months. The topics and evidence categories are itemised in the order of priority, with the most frequently commented on listed first. It is intended to be a supportive guide that can be used as a checklist to help practices identify, review, and mark off whether they have the associated evidence in place to provide reassurance that they are inspection-ready. It also signposts Agilio members to the relevant support available to assist them with implementing the relevant evidence. This document does not include all topics and evidence categories; it only highlights the most common themes identified over the last quarter. It is important to note that inspectors will examine other topics and pieces of evidence not covered in this document.

If you would like further details on how Agilio can support you, please call 0330 165 9711

Clinical Governance

Competence and leadership

Inspectors will check that the practice has strong leadership, that managers are competent, and that clinical management is efficient. They expect leaders to demonstrate an understanding of their roles, responsibilities, and legal requirements to support good governance and ensure that compliance arrangements are effective. This includes allocating appropriate time for governance and compliance-related duties, ensuring information is shared and cascaded effectively, promoting a transparent and open culture, and following up on comments, suggestions, and action plans to demonstrate a commitment to making continual improvements.

iManage provides a remote compliance management solution that is designed to supplement and support this.

Policy management

Inspectors will check that the governance system includes policies, protocols and procedures that reflect the practice arrangements and relevant regulations and guidance. They will also seek assurances that these are regularly reviewed, updated where necessary, stored in a way that can be easily accessed by all team members, and are being adhered to.

Agilio includes a digital policy editior, send-to-team ability, and document read tracking to help with this.

Conscious sedation arrangements

Inspectors will check that practices offering conscious sedation have appropriate arrangements in place to ensure this is undertaken in accordance with current guidance issued by the Dental Faculties of the Royal College of Surgeons and the Royal College of Anaesthetists. This includes carrying out checks before and after treatment, ensuring appropriate emergency equipment is available, that medicines are being managed accordingly, that sedation equipment is subjected to the necessary in-house checks, that maintenance records are available, and that staff are trained as required.

iComply members can use the ‘Conscious Sedation Arrangements Review’ activity to help with this.

CQC registered manager

Inspectors will seek assurances that a registered manager is in post, as required as a condition of registration (other than for sole traders), to oversee the legal responsibilities for the management of services for which the practice is registered. They will treat this as a breach of the regulations where a registered manager is not present and instruct that this is resolved as soon as possible.

iComply members can use the ‘CQC Registration Details Review’ activity to help with this.

Dental implants

Inspectors will check that the provision of dental implants is carried out in accordance with national guidance. They will check that staff obtain full consent, keep detailed records, and have access to the appropriate equipment for the placement of implants.

iLearn members can access a suite of training courses covering the above, plus more, to help with this.

Quality Improvement

Infection prevention and control audit

Inspectors want to see that an infection prevention audit is being undertaken every six months to evidence that the practice is regularly assessing and monitoring the quality-of-service provision. They will check that the audit is aligned with HTM01-05 and will verify whether it is being undertaken effectively by crosschecking the findings of the audit with their own findings during the inspection.

iComply members can use the ‘Digital Tool: Audit of Infection Prevention and Control’ to help with this.

Antimicrobial prescribing audit

Inspectors like to see that practices have undertaken an antimicrobial prescribing audit that reflects current guidelines from the College of General Dentistry. They expect the audit to cover whether the justification for prescribing has been documented and consider this an effective tool for practices to demonstrate quality assurance and continuous improvement in accordance with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

iComply members can use the ‘Audit of Antimicrobial Prescribing’ activity to help with this.

Clinical Record Keeping audit

Inspectors will check that patient records are being audited to ensure they contain the relevant details in line with FGDP’s Clinical Examination & Record-Keeping guidelines. They will cross-examine the audit results with their assessment of the clinical records to verify whether any inconsistencies exist between the two. Where the audit has identified gaps, they expect to see evidence of an action plan to drive improvements where needed.

iComply members can use the ‘Annual Audit of Clinical Records’ activity to help with this.

Radiography image quality audit

Inspectors want to see that practices have undertaken a radiograph image quality audit every six months that reflects the FGDP guidance notes for dental practitioners on the safe use of X-ray equipment. They will check that the audit is using the updated quality ratings of “diagnostically acceptable” and “diagnostically not acceptable”, as well as checking that it includes a retrospective analysis of a suitable sample size of images with conclusions and learning points to help drive improvements.

iComply members can use G 125C to help with this.

Disability access audit

Inspectors like to see that practices have undertaken a disability access audit to help them identify where reasonable adjustments could be considered to improve access to the service and accommodate the needs of their patients. They expect the audit to include an action plan and will seek assurances that this is being acted on. They will also check the scope of the audit to ensure it covers all access requirements and caters for all forms of disability.

iComply members can use the ‘Digital Tool: Audit of Disability Access’ to help with this.

Medical Emergencies and Equipment

Emergency drugs and equipment availability

Inspectors will physically check that all emergency medical equipment and medicines, as recommended by Resuscitation Council Quality Standards for Primary Dental Care and NICE guidelines: Medical emergencies in dental practice, are available, in date, and in good repair. They will also seek assurances that team members can access these in a timely manner; for example, they should not be locked away or located where retrieving them could delay medical assistance.

iComply members can use M 254 to help with this.

Emergency drugs and equipment checks

Inspectors will seek assurances that there is a suitable system for checking emergency equipment and drugs (including oxygen and the AED) on a weekly basis as a minimum in line with the Resuscitation Council Quality Standards for Primary Dental Care guidelines. They will check that this is being documented and will crossexamine the record with the contents of the kit to ensure it is being undertaken effectively, with no items missing, in disrepair, or expired (where applicable).

iComply members can use the ‘Digital Tool: Emergency drugs and equipment checklist’ to help with this.

Emergency resuscitation and BLS training

Inspectors will check that all team members have completed ‘hands-on’ resuscitation training in the previous twelve months, in line with the Resuscitation Council Quality Standards for Primary Dental Care guidelines and the GDC’s recommended CPD topics and will look for certified evidence of this in the staff records. They will also seek assurances by speaking with team members that they are able to demonstrate confidence and knowledge of how to respond to a medical emergency.

iComply members can access discounted CPR training through our preferred working partnerships.

Accident book

Inspectors will check that practices have a GDPR-compliant accident book available, that this is being used, and whether any completed accident records have been separated from the book and are being stored securely. They will also review any completed records to identify potential trends and will seek assurances that any accidents have been reviewed, investigated, and acted upon.

An approved accident book can be purchased directly from the Health and Safety Executive.

Blood and bodily fluid spillage kit

Inspectors expect practices to have a spillage kit available for blood and bodily fluids to ensure spills can be cleaned up safely, minimising the risk of harm to individuals and preventing the spread of potentially infectious agents.

A suitable spillage kit can be purchased from the Agilio Dental Shop.

Equipment and Facilities Maintenance

Electrical Installation Condition Report (EICR)

Inspectors will check that the electrical mains have been inspected and tested by a competent person and will seek evidence of the five-yearly electrical fixed wire testing certificate to demonstrate this. They will check the certificate to ensure there are no outstanding remedial works and that it provides a ‘satisfactory’ outcome. Where remedial works have been undertaken, they will check that there is sufficient evidence on file to verify this, such as a ‘minor electrical works certificate’ or equivalent documentation.

iComply members can use the ‘5 Year Electrical Test (EICR)’ reminder to help with this iComply members.

Autoclave maintenance

Inspectors will check that autoclaves are being serviced annually (or in line with the manufacturer’s instructions if different) and undergo thermometric validation (a process which uses independent measuring equipment to ensure the autoclave reaches the temperature and pressures it requires). They will check for certified evidence to ensure the equipment is fit for use. This includes any spare back-up autoclaves stored at the practice.

iComply members can use the ‘Autoclave service reminder’ to help with this.

Compressor maintenance

Inspectors will check that compressors are being serviced regularly in line with the manufacturer’s instructions and that a Pressure Vessel Inspection (PVI) is carried out in line with the Written Scheme of Examination (WSE), usually every 12-24 months. They will look for certified evidence of this and seek assurances that any actions identified have been completed within a reasonable time frame to demonstrate that the equipment is safe and fit for use.

iComply members can use the ‘Compressor service reminder’ and ‘Compressor PVI reminder’ to help with this.

Building and facilities maintenance

Inspectors will often check to see if the practice has suitable systems in place to maintain the building/facilities and will undertake a sweep of the premises to verify if the building, fixtures and fittings are in a good state of repair, and that the facilities are maintained in a clean, safe and secure manner.

iComply members can use the ‘Task’ functionality to record and address any disrepair issues to help with this.

Portable Appliance Testing (PAT)

Inspectors are checking that Portable Appliance Testing (PAT) has been carried out and will look for a certificate of testing to demonstrate this. They expect the frequency of testing to be undertaken in line with the tester’s recommendations (annual as per best practice) and will seek assurances that any failed appliances have been appropriately repaired or replaced.

iComply members can use the ‘Portable Appliance Test (PAT) reminder’ to help with this.

Fire Safety

Fire risk assessment

Inspectors will check that a fire risk assessment has been completed and will seek assurances that this has been done by someone competent, i.e., with the appropriate training, knowledge and experience. They will check that the assessment has been reviewed (at least annually), is up to date (reflecting any changes to the building or processes), and that any recommendations or actions have been acted on. They will also compare the assessment with their findings on the day of the inspection to verify whether the assessment is accurate and takes account of any areas of concern identified.

iComply members can access a discounted fire risk assessment through our preferred working partners.

Fire safety management procedures

Inspectors will check that adequate fire safety management procedures are in place and will seek assurances that the protocols are appropriate for the practice’s needs. They will check that the procedures cover evacuation plans, including arrangements to assist disabled persons, and will consult with the team to ensure their knowledge of the arrangements reflects those in the fire management plans.

iComply members can use M 233-FSP and M 266F to help with this.

Fire detection system availability/maintenance

Inspectors will check that a suitable fire detection and warning system is in place that meets the requirements of the fire risk assessment. They will also look for certified evidence that this is being maintained every six months, that it is in good working order, and that any remedial actions or recommendations have been dealt with in a timely manner.

iComply members can use the ‘Fire alarm service reminder’ to help with this.

Fire detection system checks

Inspectors will check that in-house weekly inspections and testing of the fire alarm system are being carried out to verify that the system is in good working order. They will look for documented evidence of these checks and seek assurances that any concerns or actions identified have been addressed promptly.

iComply members can use M 266D to help with this.

Emergency lighting system checks

Inspectors will check that in-house monthly inspections and testing of the emergency lighting system are being carried out to verify that the system is in good working order. They will look for documented evidence of these checks and seek assurances that any concerns or actions identified have been addressed promptly.

iComply members can use M 266D to help with this.

Medicines Management

Prescribing, handling and dispensing medicines

Inspectors will check that suitable arrangements are in place for the safe management of medicines. This includes ensuring medicines are kept secure and implementing a recording system that details who a medicine was prescribed to, when, the quantity and batch number. They will also seek assurances that patients are being provided with information about the medicines, such as the dose and possible side effects, and will look for evidence that medicines are being correctly labelled when dispensing. In addition, inspectors will check the justification for the medicine is documented in the patient record.

iComply members can use M 233-DMG to help with this.

Prescription pad log

Inspectors will check that NHS prescriptions are being monitored in accordance with current guidance to track their use and prevent fraudulent misuse. They expect the log to be pre-populated with serial numbers for more effective and secure monitoring and will seek assurances from team members that they are aware of the process to follow should a prescription form go missing. They will also check that prescription forms are not being pre-stamped or pre-signed before use.

iComply members can use M 268G to help with this.

Storage of local anaesthetic cartridges

Inspectors will actively check that LA cartridges are in date, being kept in a sterile environment within their blister packs to prevent them from being exposed to aerosols, and are then being decanted from their blister packs at the point of use.

iComply members can use the guidance document M 268 to help with this.

Medicine stock control

Inspectors will check that stock rotation is being recorded and that stock control of medicines is secure and effective to ensure that none are missing. This includes monitoring the stock of antimicrobials and ensuring expiry dates and batch numbers are present.

iComply members can use M 268E to help with this.

Refrigerator temperature checks

Inspectors will check that the temperature of the fridge storing medicines is monitored and logged daily to ensure it remains between 2 and 8 degrees Celsius. If the temperatures have been recorded outside of this range, they will seek assurances that the appropriate action has been taken. They will also check that the fridge is not being used for storing other items, such as food and drink.

iComply members can use the ‘Digital Tool: Daily fridge temperature log’ to help with this.

Recruitment

Staff files

Inspectors will examine a sample of staff files to seek assurances that they include all the statutory evidence outlined in Regulation 19 and Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes a photo ID, DBS check, references, qualifications, GDC registration, full employment history, and the reason why previous employment ended (if the employment involved working with children or vulnerable adults).

iComply members can use M 249 to help with this.

Recruitment policy and procedures

Inspectors will check that a recruitment policy and procedure is present to help the practice employ suitable staff, including agency or locum staff. They will check that this follows relevant legislation, i.e., Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and that it is being adhered to during the recruitment process.

iComply members can use M 222H and M 233-RXO to help with this.

Staff inductions

Inspectors will check that all staff have completed a structured induction programme. They will look for evidence of this, such as documented records, and expect these to contain information regarding what was discussed as part of the induction process. They expect inductions to include topics such as safeguarding, medical emergencies, and radiography. To verify this, inspectors will seek assurances from newly appointed team members that these records accurately reflect what they were inducted on.

iComply members can use the ‘Induction and Probation Procedures Review’ activity to help with this.

Immunisation records

Inspectors will check that staff recruitment files include evidence of vaccinations for clinical team members, particularly Hepatitis B antibody levels, to ensure that they have adequate immunity for vaccine-preventable infectious diseases before commencing their employment.

iComply members can use M 257J to help with this.

Hepatitis B non-responder risk assessment

For team members with an unknown immunisation status, and those who are non-responders, inspectors will seek evidence that a suitable risk assessment has been undertaken to ensure that the appropriate control measures have been put in place to mitigate the risk of contracting vaccine-preventable infectious diseases.

iComply members can use M 257TA to help with this.

Radiation Protection

X-ray routine assessment (performance test)

Inspectors will seek certified evidence that all X-ray units have undergone their three-yearly performance tests, usually undertaken by the appointed Radiation Protection Advisors (RPA), to verify that the equipment is still fit for clinical use and that all safety devices are in good working order.

iComply members can use the ‘X-ray routine assessment reminder’ to help with this.

X-ray service (electrical and mechanical testing)

Inspectors will look for certified evidence that all X-ray equipment has been serviced as per the manufacturer’s instructions, usually every twelve months, and that any required actions have been completed within a reasonable timeframe.

iComply members can use the ‘X-ray service reminder’ to help with this.

Radiation protection procedures (RPF File)

Inspectors will check that the required radiation protection information and arrangements are documented and available to demonstrate compliance with the Radiation Regulations 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017 to ensure the safety of X-ray equipment, including any handheld X-ray equipment. They will check the Radiation Protection policies and procedures, usually provided by the appointed Radiation Protection Advisor (RPA) as part of the Radiation Protection File, to ensure all information is present, up-to-date, and accurate.

iComply members can use the guidance document M 275D to help with this.

Local Rules (Radiography)

Inspectors will check that local rules are readily available for each controlled/supervised area and that these contain up-to-date information reflecting current regulations and guidance, including the X-ray equipment they relate to, the appointed Radiation Protection Adviser (RPA), operator instructions, name and address of the practice, and names of the authorised operators.

iComply members can use the ‘Local Rules Review’ activity to help with this.

Radiography and radiation protection training

Inspectors will check that operators of X-ray equipment have completed the highly recommended five hours of IR(ME)R update training to meet the GDC continuing professional development requirements, and will seek certified evidence to demonstrate this.

iLearn members can access a suite of training courses covering the above, plus more, to help with this.

Workforce

Staff training matrix

Inspectors will seek assurances that the practice has sufficient oversight of staff training and will check what arrangements are in place to ensure this is being monitored, that training requirements are kept up-to-date, and are being reviewed at the required intervals.

iComply members can use M 223F to help with this.

Continuing Professional Development (CPD)

Inspectors will check that staff have completed CPD relevant to their role to maintain their registration with the General Dental Council (GDC). They will request certified evidence of the training undertaken and will check that these have not expired. Examples of the training they expect staff to have undertaken include autism & learning disability awareness, fire safety, legionella awareness, sepsis awareness, infection prevention & control, and awareness around the Mental Capacity Act.

iLearn members can access a suite of training courses covering the above, plus more, to help with this.

Staff training needs

Inspectors will check that GDC registered staff have a Personal Development Plan (PDP) in place and are being provided with opportunities to discuss their training needs, such as informal discussions, appraisals, one to one meetings etc. They will also seek assurances from staff that they feel supported by the practice leadership team or management to further develop themselves and take on lead roles and responsibilities where available.

iComply members can use the ‘Team Training Arrangements Review’ activity to help with this.

Appraisals

Inspectors will check that annual appraisals are being carried out and documented for team members and will seek assurances from staff that these provide them with the opportunity to discuss learning needs, general well-being and aims for future professional development.

iComply members can use the ‘Prepare for and Schedule Annual Appraisals’ activity to help with this.

Staff meetings

Inspectors will check that practice meetings are being regularly carried out and documented. They will check the meeting minutes to verify that a range of topics are being discussed and expect the meetings to also cover staff training needs and feedback/learnings from any events, incidents or complaints. They will also seek assurances that the meeting minutes are being shared and communicated with any team members who were not present during the meeting.

iComply members can use the various ‘Practice Meeting Agendas’ and ‘Meeting Register’ to help with this.

Infection Prevention Control and Decontamination

Infection prevention and control procedures

Inspectors will check that IPC procedures are in place and that they accurately reflect published guidance, specifically HTM 01-05. They will also check that the procedures have been adapted to account for the protocols, sterilisation processes, and equipment used in the practice. In addition, they will seek assurances that staff can demonstrate knowledge and awareness of the IPC procedures and that these have been embedded effectively, including effective hand hygiene and the appropriate use of clinical clothing/PPE.

iComply members can use M 257B to help with this.

Decontamination procedures

Inspectors will check that the decontamination processes are being carried out in line with HTM 01-05 and the practice IPC procedures. They will check how instruments are being transported to and from the decontamination facilities, the process for cleaning, sterilising, and wrapping instruments, and how instruments are being stored to ensure they are not subjected to any cross-contamination risk. They will also seek assurances that single-use items are not being reprocessed and wire brushes are not used for cleaning instruments.

iComply members can use M 257B to help with this.

Legionella risk assessment

Inspectors will check that a legionella risk assessment has been completed and will seek assurances that this has been done by someone competent, i.e., with the appropriate training, knowledge and experience. They will check that the assessment has been reviewed (at least annually), is up to date (reflecting any changes to the building, such as renovations or extensions), and that any recommendations or actions have been acted on. They will also compare the assessment with their findings on the day of the inspection to verify whether the assessment is accurate and takes account of any areas of concern identified.

iComply members can access a discounted legionella assessment through our preferred working partners.

Infection prevention and control (IPC) training

Inspectors will check that team members have undertaken appropriate training in infection prevention and control (disinfection and decontamination) as highly recommended by the GDC continuing professional development requirements. They will seek assurances that this has been undertaken by looking for certified evidence of this within the staff files.

iLearn members can access the ‘Infection Control Update‘ training course to help with this.

Legionella procedures

Inspectors will check that the practice has adequate procedures in place to monitor and mitigate the risk of Legionella, or other bacteria, developing in the water systems and that these reflect the findings of the Legionella risk assessment.

iComply members can use M 233-LEM to help with this.

For more support with dental compliance and CQC inspections, speak to our team.

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