Boulevard 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.

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 were encouraged to participate in medical emergency scenario training. 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. The property is owned by the local authority. 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. The storage of these should be reviewed to ensure staff can access these in a timely way. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained.

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. A fire safety risk assessment was carried out in line with the legal requirements. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sepsis awareness and lone working. The provider should improve the practice’s sharps procedures to ensure the practice is compliant with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. The sharps risk assessment did not assess the risks from the range of sharp items in use at the practice, and staff were observed on the assessment day, not following the correct procedures in place to protect them. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out, but these had not highlighted that the documented justification to prescribe antimicrobials was not in line with nationally agreed guidance. We signposted them to updated audit tools to support their processes.

At the time of our assessment, the patients felt there were enough staff working at the practice. They were able to book appointments when needed.

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 annual appraisals, during clinical supervision, 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. Staff told us they had received a structured induction programme, which included safeguarding.

The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. We highlighted where the effectiveness of vaccinations to protect staff against blood-borne viruses is unknown, individual risk assessments should be in place. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had a structured induction, and clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

Patients told us that the practice looked clean.

Staff told us how they ensured the premises and equipment were clean and well maintained. Procedures for infection prevention and control had been put in place for staff to follow. Staff told us that single use items were not reprocessed.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. On the day of the assessment, staff did not consistently follow infection control principles, including the use of personal protective equipment (PPE). The practice should improve infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices. In particular, ensuring heavy duty gloves are worn by staff to protect them when handling instruments and ensuring the solution for manually cleaning instruments is at the correct temperature. Hazardous waste was segregated and disposed of safely.

The practice had infection control procedures which reflected published guidance. However, these were not consistently followed. The equipment in use was maintained and serviced. We highlighted that validation tests were not consistently documented in the logbook and therefore could not be evidenced. 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.