CQC inspections – Case Study with Dental Compliance Consultant Sofia Mendes

When the CQC inspection day arrived, the inspectors attended as expected, accompanied by a clinical advisor. This is typically a registered dental professional, often a dentist, hygienist, or dental nurse, whose role is to assess clinical standards and day-to-day practice. On arrival, the inspectors were welcomed into the practice, signed into the visitors’ book, and taken on a short, structured walkthrough. A comfortable space had been prepared for them so that we could begin with brief introductions and an overview of the practice, including its ethos and long-term vision from the owner’s perspective. This set a calm and confident tone for the inspection and reflected the preparation that had taken place well in advance.

Process of CQC inspections

From this point, the inspection naturally divided into two parallel streams. The practice principal accompanied the clinical advisor, while I remained with the CQC inspector. The clinical advisor began by reviewing a range of clinical records across different clinicians to assess consistency, completeness, and appropriate clinical justification. Clinical drawers were checked to ensure all materials were in date and that there was a clear system for identifying and removing expired stock. Importantly, the team were able to demonstrate a documented process for managing sterilised instruments stored long-term, including the reprocessing of any instruments that had been kept in drawers for over a year.

The clinical advisor then moved into the decontamination room, where one of the dental nurses was asked to explain and demonstrate the full decontamination process from start to finish. From the moment instruments left the surgery in a dirty box, the workflow was clearly explained and confidently followed. Instruments were placed in the designated dirty set-down area, hands were washed, and appropriate PPE was donned. Manual cleaning was carried out using water below 45 degrees with the correct cleaning solution, followed by rinsing and placement into the ultrasonic bath. After ultrasonic cleaning, instruments were rinsed again, visually inspected, and then pouched for sterilisation. Depending on the cycle required, instruments were processed through either a vacuum or non-vacuum autoclave, with post-sterilisation inspections carried out on completion. Any instruments showing debris were reprocessed, while those that passed were pouched, double-dated, and signed by the nurse. The process was smooth and confident, not because it had been rehearsed for the inspection, but because it reflected how the team worked every day.

Importance of supporting documentation during CQC inspections

Supporting documentation was readily available throughout. The team were able to show fully completed decontamination logbooks, ultrasonic bath records, and daily and weekly autoclave logbooks for both machines. Needlestick injury posters were clearly displayed in surgeries and the decontamination room, with up-to-date contact details. The accident book was reviewed and showed appropriately recorded incidents, demonstrating transparency and learning rather than avoidance. Emergency preparedness was also assessed, with all emergency drugs in date, stored correctly, and supported by clear checking procedures. Weekly emergency drug checks and daily oxygen and defibrillator checks were clearly documented and up to date.

Questions from CQC inspector 

While this was taking place, I worked closely with the CQC inspector, who had a structured list of questions and a specific set of documents she wanted to review. Thanks to the preparatory work completed beforehand, all requested documentation was easily accessible, allowing us to work through each item in detail. The inspector focused not only on whether documentation existed, but whether it was meaningful and actively used. Maintenance records were reviewed to confirm that servicing had been completed within required timeframes and that any issues identified had been appropriately addressed. Particular attention was paid to the fire risk assessment and legionella risk assessment, with clear questions around whether actions recommended by external engineers had been completed and where the evidence of this could be found. Because action plans and follow-up records had already been implemented, it was straightforward to demonstrate that risks were being actively managed rather than simply documented.

Staff records and CPD were also reviewed in depth. Although CPD had initially been one of the more challenging areas during preparation, this had been addressed ahead of the inspection. All staff files were up to date, certificates were present, and CPD evidence was saved both in individual staff folders and within a central, inspection-ready CQC folder.

Timescales for CQC inspections

The inspection itself lasted approximately three to four hours. Once the document review and initial discussions were complete, the inspector carried out a further walkthrough of the practice to confirm that what had been seen on paper matched what was happening in reality. She spoke individually with members of the team, including associates, the hygienist, dental nurses, and reception staff. They were asked whether they felt listened to, whether they felt safe in their working environment, and whether they felt respected and supported. The responses were consistently positive, with team members expressing genuine pride in the practice and enjoyment in their roles.

Patient experience was also explored. The inspector reviewed patient feedback that had already been gathered and kindly shared this with the practice, as it was overwhelmingly positive. In addition, she spoke directly with several patients in the waiting area. Patients confirmed that treatment was fully explained, consent was obtained appropriately, treatment plans were discussed in detail, all options were clearly presented, and nothing proceeded unless they fully understood and felt comfortable. Patients also commented on being given sufficient time to ask questions and make informed decisions, reinforcing that consent and communication were being handled consistently and well.

CQC inspection overview 

Overall, the inspection went smoothly not because of last-minute preparation, but because strong systems, clear processes, and a supportive culture were already embedded within the practice. Documentation, clinical standards, governance, and team engagement were aligned and that alignment was evident throughout the inspection.

If you have an upcoming CQC inspection, contact us today for expert compliance guidance on 0330 088 2275 or info@buxtoncoates.com 

Sofia Mendes, Dental Compliance Consultant