Ormond Terrace Dental

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; staff we spoke with were able to describe these to us. Our assessment highlighted that systems and processes in place were not always followed and some examples where risk had been identified but was not acted on. Staff told us they felt the reporting of risks was encouraged.

Emergency equipment and medicines were not available in accordance with national guidance. Daily checks on this equipment and medicines had failed to identify missing items or that the medical oxygen for use in an emergency was below the recommended level. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support. The provider could not evidence that staff providing treatment to patients under sedation had completed immediate life support and airway management training.

The premises were visibly clean. We observed that paint in the decontamination room was peeling. Cleaning equipment was not stored in accordance with recognised guidance.

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. However, our assessment identified that labelling of medicines was not in accordance with regulations. Antimicrobial prescribing audits were carried out.

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

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

We were told that all newly appointed staff had a structured induction, which included safeguarding training. Our checks showed that not all staff had a documented induction. The provider was unable to demonstrate that clinical staff operating the cone-beam computed tomography (CBCT) machine had completed training to the appropriate level. Evidence of Ionising Radiation (Medical Exposure) Regulations (IR(ME)R update training was not available.



Processes to support and develop staff with additional roles and responsibilities were in place but not always implemented.

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, and they were happy to work in the practice.

Staff discussed their training needs during annual appraisals, 1 to 1 meetings and practice team meetings. They also discussed learning needs, general wellbeing and aims for future professional development.

The practice had documented infection control procedures that reflected published guidance. This included procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment.

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 and demonstrated knowledge and awareness of infection prevention and control processes. 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 when working and safely segregated and disposed of hazardous waste.

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.