Hampshire Terrace Dental Care

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 line 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.

The practice identified and managed risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and overall, this was reflected in our findings.

Staff could access emergency equipment and medicines that were checked in line with national guidance. However, we noted the Automated External Defibrillator (AED) indicated that the battery was low and required changing. Following the inspection, we received evidence that a replacement battery had been ordered. Staff knew how to respond to a medical emergency, but not all had completed training in emergency resuscitation and basic life support every year.

The practice managed fire safety well, and fire exits were clear and well signposted. However, the fire risk assessment included a recommendation that fire resistant doors were installed. This was also noted on the previous fire risk assessment and had not been actioned. Following the inspection, we saw evidence that this had been arranged but remained outstanding due to contractor delays.

The premises were visibly clean, well maintained and free from clutter. However, we noted the surfaces of an operator’s stool in 1 surgery and the arm of the dental chair in another, were not intact and impervious, which could compromise effective cleaning of these.

Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, this was not always being followed. For example, we did not see information about any physical or mental health condition relevant to a person’s capability to perform tasks for 7 staff; evidence of immunity to Hepatitis B was not available for 2 staff and appropriate evidence of conduct in previous employment was not always obtained. Following the inspection, we received confirmation that the practice was addressing these areas.

Improvements to the practices protocols and procedures were needed to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. We saw some gaps in mandatory and recommended training topics.

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

Newly appointed staff had an appropriate role specific structured induction.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions.

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

The practice had infection control procedures that reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, a recommendation in the risk assessment to replace 2 water heaters had only been actioned for 1 of the identified units and the hot water in the decontamination room and the staff toiler were not reaching the required temperature. Following the inspection, we received evidence that this had been addressed and that the temperatures were now within the appropriate range.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. However, we noted the incorrect sharps bins were in use, and sanitary waste bins were not available. Following our feedback, we received confirmation that these were now in place and had been added to the practice’s waste contract.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

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