Firswood 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 demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice, and this was reflected in our findings.

The practice had suitable procedures for the management of sharps and staff knew what to do in the case of a sharp’s injury. However, information displayed within sharps injury posters contained out-of-date information. The provider took immediate action during the assessment day. They created a new poster and placed these in necessary areas.

Emergency equipment and medicines were available, and staff could access these in a timely way. We noted that checks on emergency equipment and medicines were not done in accordance with national guidance, as a result, some equipment was missing. All missing equipment was ordered during the assessment day and a new weekly medical emergency kit checklist was created during the assessment. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff 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. However, the practice should improve the processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002. The practice had not carried out risk assessments in relation to the safe storage and handling of all the substances hazardous to health within the practice. We discussed this with the provider and were assured these would be completed within the next 4 weeks.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. We noted the Electrical Installation Condition Report (EICR) and the service for the compressor were overdue. The EICR was scheduled for 20 March 2025 and the compressor service was scheduled for 26 March 2025.

The management of fire safety was effective, and fire exits were clear and well signposted. However, a fire drill carried out on 18 February 2025 did not record the evacuation time. A fire drill was carried out on 21 March 2025 and the evacuation time recorded. We noted 5 outstanding actions had not been completed following the fire risk assessment from 11 May 2023. We discussed this with the provider and were assured any actions would be rectified.

The practice had systems for appropriate and safe handling of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff, however they were not always followed.

On the day of assessment, we checked 7 recruitment files. We noted that pre-employment checks, including Disclosure and Barring Service (DBS) were not carried out for 6 members of staff before they commenced employment at the practice. Hepatitis B titre levels were not obtained for 1 member of the clinical staff. Titre levels are required to indicate levels of antibodies following a vaccination to ensure the vaccine has been effective. The practice should ensure they consistently follow their recruitment policies and procedures, to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had an appropriate role specific structured induction.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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

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. We saw, and staff confirmed that single use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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.