Kirkstall Road Dental Practice

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.

The practice had processes to identify and manage risks and staff we spoke with were able to describe these to us. 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 staff could access these in a timely way. The medicines were checked in accordance with national guidance. However, the equipment checks were not always effective, as they had not identified that some items of necessary equipment were missing or past their expiry date. Immediate action was taken to obtain replacements, and we were assured checking processes would be improved to prevent reoccurrence. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. The management of fire safety was effective, and fire exits were clear and well signposted. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. However, not all records were available on the day of our visit, and some evidence was sent after the assessment. The practice should improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Oversight was not in place to ensure clinical staff accessed vaccinations and ensure these were effective in a timely way. The practice should take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases. All newly appointed staff had a basic introductory induction. We highlighted these should be role specific and structured. The provider ensured 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. Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children. Staff stated they felt respected, supported and valued, and they were proud to work in the practice. Staff discussed their training needs during annual appraisals, 1 to 1 meetings, during clinical supervision, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development.

The practice had infection control procedures that reflected published guidance. A Legionella risk assessment had been carried out, but the provider was yet to receive the report. There were some processes to ensure water quality. However, we highlighted that hot water temperatures appeared below the accepted range and lesser used outlets should be flushed weekly to prevent Legionella or other bacteria, developing in water systems. The practice should take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ The practice had cleaning procedures and schedules to ensure effective cleaning. We observed the decontamination of used dental instruments, which aligned with national guidance. Staff received appropriate training. However, oversight of the trainee dental nurses could be improved to ensure they demonstrate knowledge and awareness of the procedures. In particular, marking pouches of sterilised instruments with the reprocessing date and the storage of dental burs. The equipment in use was maintained and serviced as per manufacturers’ instructions. We saw, and staff confirmed that single use items were not reprocessed. Staff followed infection control principles, including the use of personal protective equipment, and safely segregated and disposed of hazardous waste. The practice completed infection prevention and control audits in line with current guidance. We highlighted the audits should identify the lack of handwashing facilities in the decontamination room and plan to address this in the future.

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