St Mark Dental Surgery

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. The provider had made improvements in relation to the regulatory breaches we found at our inspection on 11 November 2024.

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.

At the assessment on 6 January 2025, we found the practice had made the following improvements to comply with the regulations: We saw that the gas boiler had been serviced. A Radiation Protection Advisor/Medical Physics expert (RPA/MPE) had been appointed and was scheduled to come into the practice on 20 January. Whilst we saw that a radiography audit had been carried out, further improvement could be made to ensure results were analysed and evaluated against national guidance to drive improvement. We saw that the annual service for the autoclave (a machine that uses steam under pressure to kill harmful bacteria, viruses, fungi, and spores on items that are placed inside a pressure vessel) had been carried out. The Employer’s Liability Insurance Certificate was displayed as required by government legislation. We saw that a process had been implemented to ensure the medical emergency drugs and equipment were checked at least weekly in accordance with national guidance. We saw that a booking had been made for 9 January for a Legionella risk assessment. Water temperature checks to ensure the temperature of hot and cold water in the practice was within the required range were still not being carried out.

At the assessment on 6 January 2025 we found the practice had made the following improvements to comply with the regulations: We saw that IR(ME)R training had been completed by all relevant staff members apart from 1 clinician. We saw that the safeguarding policy had been updated and information was available throughout the practice. We saw that all staff apart from 1 had completed safeguarding training at a level suitable to their role, staff had received training in infection prevention and control (IPC), fire awareness, and some staff had completed training in learning disability and autism. We also saw that Basic Life Support training had been booked to be provided on 15 January. The practice had implemented arrangements to ensure staff training was up-to-date and reviewed at the required intervals, yet time was needed for this to be embedded. Following discussions with the Regional Manager, we saw that there was now a process in place for the induction and recruitment of new staff members. We saw that Disclosure and Barring Service (DBS) certificates had been obtained for all staff apart from 1 clinician, and we saw a template was being used to obtain satisfactory evidence of conduct in previous employment for staff. Identification checks had been completed for all staff apart from the provider. We saw evidence of the immunisation status for Hepatitis B for all members of staff apart from 1 clinician. Further improvements were required to ensure that the 2 trainee dental nurses employed at the practice received appropriate support, training and supervision at the practice by a named clinician registered with the General Dental Council. Additionally, staff appraisals had not been carried out, yet the provider told us these would be completed in January.

The judgement for Infection prevention and control is based on the latest evidence we assessed for the Safe key question.

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