Friar Street 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 and had taken into consideration appropriate guidance. The provider had made improvements in relation to the regulatory breach we found at our on-site inspection on 9 October 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 focused inspection on 2 April 2025, we found the practice had made the following improvements to comply with the regulations.

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.

Biohazard spillage kits were available for staff to use.

Records to confirm that the defibrillator (AED) was checked, at least weekly, was available. Records to confirm that the oxygen and emergency equipment was checked, at least weekly, was available.

Glucagon was stored in a fridge. The fridge was monitored to ensure its’ temperature remained between 2 and 8 degrees Celsius.

Hazardous substances were stored in line with control of substances to health (COSHH) regulations. COSHH risk assessments and safety data sheets were available for every COSHH identified product used in the practice.

A clinical waste bin, stored on the fire escape route, was locked to prevent unauthorised access and interference.

Water temperature monitoring was carried out appropriately.

Since our last inspection the practice stopped providing treatment under conscious sedation. Staff told us they referred patients out for this service and evidence of this was seen in their referral tracker.

The fire exit route from the second floor was removed from service by the landlord due to repairs being required. We referred this matter to Berkshire Fire and Rescue Service and have since been advised that their own investigations are underway.

At the focused inspection on 2 April 2025, we found the practice had made the following improvements to comply with the regulations.

Records to confirm that emergency lights were tested and serviced appropriately were available.

Records to confirm that fire drills were carried out were available.

A fire safety risk assessment was carried out by someone who could demonstrate competency in the management of fire safety.

X-ray equipment was not left switched on when treatment rooms were vacated.

Rectangular collimators were present on the x-ray equipment in all treatment rooms.

Records to confirm that performance checks for the x-ray equipment in treatment rooms 2, 4 & 5 had been carried out were available.

A legionella risk assessment was carried out on 6 September 2024. The resulting actions required from this assessment were completed.

A lone working risk assessment had been carried out for hygienists who worked without chair side support.

Records to confirm that the air conditioning units had been serviced were available.

At the focused inspection on 2 April 2025, we found the practice had made the following improvements to comply with the regulations.

All but one staff completed basic life support training in the previous 12 months. We noted that one new member of staff had completed on-line medical emergency kit management training. We were assured this staff member would undertake further relevant training as soon as practicably possible.

All clinical staff completed infection prevention and control training.

All staff completed safeguarding children and adults at risk training.

All staff completed fire safety training in the previous 12 months.

All staff completed interacting with people with a learning disability and autistic people training.

A foundation dentist worked with a qualified and registered dental nurse.

At the focused inspection on 2 April 2025, we found the practice had made the following improvements to comply with the regulations. An annual infection prevention and control statement was available. A low volume suction unit in treatment room 5 was seen to be repaired effectively. The floor and dental treatment chair seals in treatment room 1 and 4 were complete and impervious. A foot operated clinical waste bin was available in treatment room 1. Local anaesthetic ampules were stored correctly (blister packed) in treatment room drawers. The availability and management of needle guards, clinical sharps bins and sharps disposal aligned with the practice's sharps risk assessment. Treatment room cleaning checklists were completed appropriately. Staff had oversight of the standards of cleaning.

Cleaning of dental instruments was carried out in line with national infection prevention and control guidance. Instruments were inspected appropriately after being manually cleaned and before being placed in the steriliser. Decontamination glove and brush change logs were available. Used dental treatment instruments were kept moist in an appropriate way while they waited to be re-processed. Records to confirm that routine vacuum autoclave validation checks had been carried out were available. Records to confirm that weekly air leakage tests, for every autoclave, had been carried out were available. Instruments were spaced out on trays to prevent overloading when being sterilised.

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