James Pegg Dentistry

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. Sepsis awareness could be improved, we highlighted this to staff and were assured it would be addressed.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health, and hazardous substances were clearly labelled and stored safely. The practice should ensure they have access to safety data sheets for all substances used at the practice.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. We did not see evidence of the compressor service, and the 5-yearly fixed wiring test was last carried out in 2016. We raised this with the practice and have had confirmation that both are booked in.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. However, the 3-yearly performance test for the intra-oral X-ray unit was almost a year overdue. The practice assured us this had been booked in.

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

The management of fire safety was not always effective. A fire safety risk assessment was carried out. However, we were not assured it was completed by a competent person. The risk assessment did not consider the compressor which was housed in a small cupboard containing combustible materials and no fire-detection equipment. The practice’s emergency lighting system was a series of plug-in sensor lights.

We raised this with staff and are assured they will get a new risk assessment completed by a competent person.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, Disclosure and Barring Service (DBS) checks were not always carried out at the point of recruitment. We raised this with staff and were assured they would be done going forward.

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. However, we noted this did not include safeguarding. We raised this with staff and were assured it would be included going forward.

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.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during appraisals, 1-to-1 meetings and practice team meetings.

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.