Weaverham 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 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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff we spoke with told us that equipment and instruments were well maintained and readily available. The provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice, and the reporting of risks was encouraged.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. The practice ensured the facilities were maintained in accordance with regulations. A fire safety risk assessment was carried out in line with the legal requirements. The management of fire safety was effective. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety. The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. This included cone-beam computed tomography (CBCT). We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings. The practice should improve their governance processes to maintain oversight of radiation protection. In particular, ensuring recommendations from critical examination reports are addressed in a timely manner.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during annual appraisals, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. Staff we spoke with demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had a structured induction, and clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation. However, the practice should ensure they consistently follow them so that appropriate checks are completed prior to new staff commencing employment. We noted disclosure and barring service (DBS) checks had not been consistently sought at the time of recruitment for some staff members. The practice had identified this prior to the assessment and had applied for new DBS checks where required. We discussed this with management and were assured the recruitment policy would be consistently followed going forward.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. 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.

Staff demonstrated knowledge and awareness of infection prevention and control processes, and we saw single use items were not reprocessed. Staff had appropriate training, and the practice completed infection prevention and control (IPC) audits in line with current guidance. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. We noted one of the autoclaves, a machine used to sterilise reusable instruments, had not undergone its annual validation test. The practice acted immediately and provided evidence on the assessment day that it had been booked for 17 January 2025. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. Monthly hot and cold-water temperature checks were completed and logged. However, the governance processes for oversight and ongoing monitoring should be improved. We highlighted that the temperature ranges were not within the those required by the risk assessment, and that this had not been identified nor addressed by practice staff. The practice acted immediately, turned the boiler up on the day of the assessment and submitted evidence in the days following the assessment that the temperatures were within the required ranges.

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