Cleveland Terrace 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.

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 premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Fire exits were clear and well signposted. Fire safety equipment such as the fire alarm, emergency lighting and fire extinguishers were serviced. However, there were no internal checks to ensure it was in working order. Emergency equipment and medicines were available and checked in accordance with national guidance and staff could access these in a timely way. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions with the exception of the gas safety record which was dated September 2022. Invoices were provided for the service in 2022 and prior. However, there were no available reports to confirm the equipment had passed and was safe to use.

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). The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. The practice had systems for appropriate and safe handling of medicines. However, patient information leaflets were not given out alongside antimicrobial prescriptions as required, and antimicrobial prescribing audits were not carried out. The management of fire safety was ineffective. A fire safety risk assessment was carried out internally by someone who was not trained or competent to do so. It did not consider the compressor which was in an attic room with no fire detection equipment or the laboratory which was part of the ground floor. There was no regular testing or checks of fire alarms, emergency lighting and fire extinguishers. Fire drills were not carried out. The practice took immediate action and had a fire risk assessment completed by an external company the day after our assessment. We have seen evidence of the report, which highlighted a significant number of actions. The practice has assured us actions will be completed. The practice had not fully implemented systems to assess, monitor and manage risks to staff safety. Neither a sharps risk assessment nor a lone working risk assessment had been completed. The provider completed and submitted both risk assessments in the days following the on-site assessment.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. 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. Staff stated they felt respected, supported and valued. They were proud to work in the practice. However, staff felt the practice did not always support them to develop nor enable them to take on lead 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 staff files we saw on the day did not reflect the policy as many of the required recruitment documents were missing. Clinical staff were qualified, registered with the General Dental Council (GDC) and had appropriate professional indemnity cover. Clinical staff completed continuing professional development required for their registration with the GDC. However, the practice did not ensure their records were up-to-date. The provider submitted these documents in the days following our on-site assessment. We did not see evidence of structured inductions for newly appointed staff.

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. Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. We saw single use items were not reprocessed. Staff had appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. However, the practice had not 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.