Church Lane 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 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 and sepsis awareness.

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

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Control of Substances Hazardous to Health (COSHH) risk assessments and safety data sheets were available for staff.

We saw records of servicing and validation of most of the equipment was in line with manufacturer’s instructions. We found the compressor service was out of date.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT).

The practice managed fire safety well, and fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines. We found improvements should be made with the monitoring and stock control of dispensing medications. Following our inspection, we saw evidence that this had been addressed.

The practice had a recruitment policy and procedures that reflected relevant legislation to help them employ suitable staff. However, we found this was not always followed.

We found information for most of the staff was not available at the time of our inspection. For example, photographic identification, in date indemnity cover and evidence of Hepatitis B immunity were missing. Disclosing and baring service checks (DBS) were not carried out at the point of recruitment. Following our inspection, evidence of missing documentation was submitted for some of the staff.

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

Newly appointed staff had a basic induction to the practice.

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.

At the time of our inspection the practice did not have processes in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Following our inspection, training evidence was submitted for most of the staff.

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

Staff felt respected, supported and valued, and they were happy 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 procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. We found improvements were required as the hot water temperatures were not reaching the recommended 55 degrees Celsius and there was limescale on the taps.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

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.