Peelhouse Dental Care

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 provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice, and the reporting of risks was encouraged.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. However, we noted there was no bodily fluid spillage kit available. The practice acted immediately and submitted evidence in the days following the assessment that a bodily fluid spillage kit had been ordered. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing of equipment in line with manufacturer’s instructions. Fire exits were clear and well signposted, and the practice had the fire extinguishers servicing booked for 14 February 2025.

The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. The practice ensured the facilities were maintained in accordance with regulations. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out. The management of fire safety was not always effective. A fire risk assessment was carried out. However, the practice could not evidence that it had been done by a competent person, and we identified a few minor omissions. The provider submitted evidence following the assessment that the fire safety risk assessment had been booked for the following week. The practice had arrangements to ensure the safety of the X-ray equipment, which included cone-beam computed tomography. However, the governance arrangements for radiation protection were not always effective. Some of the required radiation protection information, such as servicing reports for some of the X-ray equipment, were not available at the time of assessment. The practice had implemented systems to assess, monitor and manage risks to service users and staff safety. However, these were not always effective and did not include lone working. The sharps risk assessment was not reflective of practice protocols and there was no lone working risk assessments for staff working alone. Improvements were also required to ensure the practice had undertaken risk assessments to minimise the risk that could be caused from substances that are hazardous to health, as identified and outlined by the Control of Substances Hazardous to Health Regulations 2002. The practice submitted evidence in the days following the assessment that a new sharps risk assessment and a lone working risk assessment had been completed.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. 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.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice had a recruitment policy and procedure to help them employ suitable staff. However, these were not in line with legislation and were not consistently followed. The policy did not detail Disclosure and Barring Service (DBS) checks nor references and the practice did not consistently request these at the time of employment. The practice had identified this omission prior to our on-site assessment and were awaiting the outcome of DBS applications for staff. We also noted there was no evidence of Hepatitis B titre levels (to indicate immunity levels to the virus) for 1 member of staff. We discussed this with the practice manager and were assured all future recruitment would be in line with legislation. The practice’s arrangements to ensure staff training was up-to-date and reviewed at the required intervals was not working effectively. On the day of assessment, we noted gaps in training for 2 staff members in safeguarding and fire awareness training. The practice acted immediately and sent evidence following the assessment that all staff had completed the required safeguarding training and fire awareness training, some of which pre-dated our assessment.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. There was no environmental cleaning log, we discussed this with the practice manager and were assured they would be completed from now on. Staff followed infection control principles, including the use of personal protective equipment (PPE). 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 noted the autoclave was overdue for its annual validation. We discussed this with staff and were assured they would check with the manufacturer whether this was required. Staff demonstrated knowledge and awareness of infection prevention and control processes, and we saw single-use items were not reprocessed. Staff had appropriate training, and the practice completed infection prevention and control (IPC) audits in line with current guidance. 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.

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