Thorley 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. Whilst there are issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk.

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, but not all staff had completed training in emergency resuscitation and basic life support every year. Staff did not carry out medical emergency scenario training.

Most emergency equipment and medicines were available, but these were not checked in accordance with national guidance and hence missing items had not been identified. These included paediatric pads for the Automatic External Defibrillator, needles and syringes for administering adrenaline, and a child inflating mask and bag. Following the inspection, we saw that these items had been ordered.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, improvements were needed to ensure that this servicing was carried out in a timely manner in the future.

The practice did not ensure that the facilities were maintained in accordance with regulations. There was no evidence of an Electrical Installation Condition Report (EICR) and in a treatment room there were exposed wires from a cut electrical cable on the dental worktop posing a potential risk. Following the inspection, we saw that the practice had enquired about having an EICR completed, and the exposed wires had been attached to a plug.

A fire safety risk assessment had been carried out in line with the legal requirements in 2016. This risk assessment referred to emergency lighting being present, yet this was not present. The fire alarm was not tested or serviced. The management of fire safety was therefore not effective. Following the inspection, we saw the practice had enquired about having a new fire risk assessment and a service of the fire alarm carried out.

The practice had some arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. However, improvements should be made to ensure that actions arising from the 3 yearly service were actioned. Following the inspection, the practice told us that these actions had been looked into, and some completed. Additionally, we saw that no quality assurance testing was taking place for the manual processing of analogue radiographs.

The practice had some risk assessments to minimise the risk that could be caused from substances that are hazardous to health. Improvements must be made to ensure that all necessary substances were included, and that the data sheets included all relevant information.

The practice had implemented some systems to assess, monitor and manage risks to patient and staff safety. However, the sharps risk assessment was not reflective of our findings as it stated that only the dentist should dispose of used needles, and we were told that nurses carried this out. Following the inspection, we were told that sharps will be disposed of in line with their risk assessment moving forward.

We noted an autoclave was on a high shelf. Although there was no other option for the site of the autoclave currently, the risks of this had not been identified in the health and safety risk assessment.

Additionally, staff we spoke with had limited awareness of sepsis.

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

Staff discussed their training needs during annual appraisals and ongoing informal discussions.

Staff we spoke with demonstrated limited knowledge of safeguarding. Information was not available around the practice for staff to know how to report a safeguarding concern. Following the inspection, we saw a photograph sent by the provider that this information was now displayed for staff.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation. We saw that 1 member of staff did not have a Disclosure and Barring Service (DBS) certificate of the correct level, and not all clinical staff had evidence of immunity to Hepatitis B. Following the inspection, we saw that an enhanced DBS certificate had been requested for one staff member, and that blood tests had been requested to verify staff’s immunity to Hepatitis B.

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

The practice did not have arrangements to ensure staff training was up-to-date or reviewed at the required intervals.

Clinical staff completed some continuing professional development required for their registration with the General Dental Council. Improvements must be made to ensure that staff were up to date with all training requirements, for example basic life support and safeguarding.

Parts of the practice appeared clean. However, there was no schedule in place to ensure all areas were kept clean. We saw that mops had not been labelled, leading to risk of cross contamination. This had not been identified in infection control audits. Following the inspection, we saw that new mops and buckets had been purchased and a labelling system was in place to reduce risk of cross contamination.

Worktop surfaces and drawers in the surgeries were damaged, broken and did not appear clean. Following the inspection, the practice told us that drawers were cleaned, and we saw that new drawer sliders had been purchased along with silicone to seal the broken areas of the worktops.

We observed the decontamination of used dental instruments, which did not consistently align with national guidance. For example, the water used for manual scrubbing of instruments was not temperature checked, and the volume of water was not measured to ensure the disinfectant was diluted in accordance with the manufacturer’s recommendations. Additionally, due to space restrictions, each treatment room contained an autoclave. One treatment room did not have a clear dirty to clean flow for the decontamination of instruments. Following the inspection, we were told that a thermometer would be used to check the water temperature, and the volume of water would now be measured. Additionally, we saw that the autoclave in the front treatment room was moved to another place within the room to facilitate the dirty to clean flow of instruments.

Hazardous waste was segregated and disposed of safely, although improvements should be made to ensure that staff disposing of clinical waste had the required evidence of immunity to hepatitis B. Following the inspection, we were told that only clinicians with evidence of Hepatitis B immunity would manage the clinical waste.

The equipment in use was maintained and serviced. Staff demonstrated some knowledge and awareness of infection prevention and control processes, and we saw single use items were not reprocessed.

The practice completed infection prevention and control (IPC) audits in line with current guidance. However, this audit did not identify issues we saw, and hence was not suitable to drive improvement. It was therefore not effective.

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.