Fillybrook House 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.

Systems for checking emergency equipment and medicines required strengthening as they had not identified that items of medical emergency kit were missing or out of date. Items that were missing or were found to be out of date were ordered immediately during our inspection. Weekly checklists required updating to ensure all items were present and expiry dates had not been exceeded.

Staff could access the medical emergency kit in a timely way. Staff knew how to respond to a medical emergency and had completed online training in emergency resuscitation and basic life support. Following our inspection, arrangements were made for both staff members to attend face to face medical emergency 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.

Fire exits were clear, well signposted and fire extinguishers were serviced annually. We found there was no routine monitoring of fire safety equipment. Following our inspection, logs were implemented to ensure fire safety equipment was in working order.

The practice had systems for appropriate and safe management of medicines.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

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 and general wellbeing during ongoing informal discussions.

Staff stated they felt respected, supported and valued and they were happy 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.

We found the local anaesthetic cartridges were not stored in their blister packs. Immediately following our inspection evidence was submitted to show these had been removed from the treatment room and replaced with new packs.

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.

Some improvements were required to the flooring in the treatment room.

The equipment in use was maintained and serviced as per manufacturers’ instructions. We found the validation of the autoclaves required strengthening as there was no monitoring of each cycle of sterilisation.

The practice completed infection prevention and control audits in line with current guidance. However, we found these did not reflect our findings on the day as the treatment room flooring required attention and there were no foot operated clinical waste bins which was not highlighted in the audit. These shortfalls were both addressed immediately following our inspection.

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