The Dental Team

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 assessment on 19 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 8 January 2025 we found the practice had made the following improvements to comply with the regulation: The leadership team described the improvements that had been made to the processes to identify and manage risks. Staff told us a new fire risk assessment had been carried out since our last assessment and a number of recommendations had been made. The provider had sought assurances regarding the basement area and the residential premises above the practice. Action had been taken to address some of the recommendations immediately, and we were told a plan was in place to complete the remaining actions in the short-term.

We noted improvements had been made to the environmental cleaning equipment to ensure it was replaced when heavily soiled and stored appropriately. On the day of the assessment, we saw the fire exits were kept clear, emergency illumination was available. Staff described the protocols in place for the management of substances hazardous to health. We noted risk assessments, to minimise the risks, were available. The risks to all staff working alone had been considered and mitigated and arrangements had been introduced to ensure patients could access care in the event of the practice closure. We saw improvements had been made to the monitoring of NHS prescription pads, to ensure all prescriptions could be accounted for. The practice had implemented audits of antimicrobial prescribing and confirmed audits for the remaining team members would be carried out in the short-term. A schedule had been introduced to ensure these are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented reflection and action points to ensure the resulting improvements can be demonstrated.

The annual gas safety certificate and the portable appliance testing (PAT) testing had been carried out. Since our last assessment, improvements had been made to the general maintenance of the practice, including areas of damp, broken and missing ceiling tiles and flooding visible in the basement area. The practice had sought guidance from their Radiation Protection Advisor in relation to the safety arrangements and the documentation contained within the radiation protection folder. In addition, radiography audits had been carried out. Improvements had been made to the systems to assess, monitor and manage risks to patient and staff safety. The sharps safety risk assessment we were shown had been updated to reflect the protocols at the practice and important information relating to the post-exposure protocols was available for staff. We saw the lower section of the boiler casing in the staffroom had been re-fitted to prevent injury. The row of properties where the practice was located, occasionally experienced localised flooding in the basement area. The provider had arranged for an external assessment of the basement area to ensure they could manage any flooding that occurs appropriately. The electrical equipment in this area had also been raised further off the ground level. The work in this area was ongoing and we received assurances from the provider that this would be completed promptly.

Staff we spoke with described the improvements they had noticed since our last assessment. Throughout the assessment process the leadership team were open and honest about the challenges and described the steps being taken to address the issues. This included the recruitment of a new practice manager and the appointment of a clinical lead within the practice. Staff commented how having this support was having a positive impact of their day-to-day roles.

From the records we were shown, we noted improvements had been introduced to ensure all checks were carried out at the point of recruitment for all newly appointed team members. On the day of the assessment, most training records were available for all staff members. Where certificates were not available, the leadership team confirmed they had requested team members carry out refresher training at the earliest opportunity.

Improvements had been made to ensure staff adhered to the infection control procedures. The practice had carried out an infection prevention and control (IPC) audit and a schedule was introduced to ensure this was carried out bi-annually in accordance with current guidance.

We saw improvements had been made to the level of cleanliness in all areas. The clinical waste bin was locked and secured and the clinical waste was stored appropriately. We saw improvements had been made to the processes for the decontamination of used dental instruments. This included improvements to the storage arrangements of the containers used to transport instruments to and from the decontamination (decon) area. The manual cleaning solution was used in accordance with the manufacturer’s guidance. Routine testing was carried out on the ultrasonic bath to ensure its efficacy had been introduced. Hand soap was used consistently. Extractor fans to enable the correct air flow in the decon room were working and clean. The washer-disinfector had been removed, as this was not in use. Eye protection was available and in use in the decon room and the heavy-duty gloves were changed frequently in line with guidance.

The practice had requested a new Legionella risk assessment to be carried out to ensure all risks were considered and could be mitigated. On the day of the assessment they had not received the report but we received assurances any actions would be completed promptly. Action had also been taken in relation to the ongoing monthly monitoring protocols to ensure accurate temperature recordings were taken and where these indicated a risk, steps would be taken to address it.

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