Ilkley Dental Care Limited

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. However, we found some of these processes were ineffective.

Most emergency equipment and medicines were available, and staff could access these in a timely way. However, these were not checked in accordance with national guidance. As a result, during our routine checks of the kit and discussions with staff we found items were missing or expired. Glucagon (which is required in the event of severe low blood sugar) was refrigerated but a thermometer was not in place to ensure the fridge maintained the accepted temperature range.

We also discussed reconsidering the location of the kit. This was wall-mounted over a radiator, which may raise the temperature of the medicines above the manufacturer’s instructions.

These issues were raised with the principal dentist who confirmed systems would be implemented to carry out weekly checks of the medical emergency kit. Evidence was provided after the assessment that replacements were immediately obtained, and a significant event was documented to prevent recurrence of this.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year, and were encouraged to participate in medical emergency scenario training.

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. However, the most recent records of servicing for the X-ray equipment were not available during the assessment. This was obtained and sent afterwards. Recommendations had been acted on and we were verbally assured that operators were operating these in accordance with the recommendations. However, improvements were needed to radiation protection governance arrangements to ensure actions were addressed in a timely way and records of servicing and actions completed were easily accessible.

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, and provide an appropriate role specific structured induction. However, these were not consistently followed. Disclosure and Barring Service (DBS) checks were not consistently carried out for clinical staff at the point of employment. We signposted the manager to information to support the implementation of the policy.

For one recently employed staff member, there was no evidence of obtaining a work history, references or a suitable role-specific induction.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Dental nurses were covered by the principal dentist’s policy, but they were not provided with the details of the policy. We saw advice was being sought to ensure this covered them for assisting with dental implants.

The practice did not obtain evidence of adequate immunity for vaccine preventable infectious diseases at the point of employment for 4 clinical staff members. We also saw known non-responders (a person who does not develop protective surface antibodies after completing a full series of vaccinations) were not risk assessed. The manager was in the process of obtaining levels for staff at the time of the assessment.

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.

The practice had some arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals for dental nurses and administrative staff. The manager had a system to assign and monitor training and staff were incentivised to complete this in a timely way. However, there was a lack of oversight of completion for clinicians and evidence of training and continuing professional development was not easily accessible. Their certificates were obtained and sent after the assessment. The practice should implement protocols and procedures to ensure staff are up-to-date with their mandatory training and their continuing professional development.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, 1-to-1 meetings, during clinical supervision and practice team meetings and ongoing informal discussions.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

The practice had infection control procedures that reflected published guidance and were followed consistently.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance.

The sharps risk assessment in the sharps policy did not reflect the range of sharps used in the practice to ensure the risks from handling these were mitigated. There was a process for staff to report any sharps injuries. However, arrangements were not in place to enable staff to access occupational health advice and support. We signposted them to resources to support them. Staff confirmed that single-use items were not reprocessed.

The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment which was provided to us after the assessment. Staff maintained dental unit waterlines effectively and carried out monthly water temperature testing. We highlighted some hot-water temperatures were below the accepted range and the log for these did not prompt the action to take if they were out of range. We were not assured all the recommendations had been acted on. In particular, assessing the suitability of flexible hoses and expansion vessels, and removing a dead leg.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

The equipment in use was maintained and serviced as per manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

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