Church Street 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.

The practice had processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. There was scope to improve the systems in place to ensure risks were well managed at the practice. We noted servicing of the gas boiler had not been undertaken since May 2022. A five yearly electrical installation report had been undertaken on 11 January 2020 with an outcome of unsatisfactory including 5 C2 ratings requiring prompt action, 11 C3 ratings recommending improvement and 1 further investigation required. The provider was not able to confirm or evidence if any action had been taken to address these concerns since the 2020 report. Following the inspection we were told a new installation report was being scheduled and the gas boiler servicing would be scheduled.

Systems for checking emergency equipment required strengthening as they had not identified that some items of the medical emergency kit were missing, including adult and child oxygen masks with reservoir and tubing. In addition, there was no portable suction and the aspirin was not dispersible. The provider ordered these immediately. There was scope to improve the equipment log to ensure all missing items were included when monitoring medical emergency equipment. Following discussion, we were assured that weekly checks of emergency equipment would be reviewed immediately.

Staff could access medical emergency equipment and medicines 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.

The premises were visibly clean, and free from clutter. However, we noted one treatment room where the flooring and work surfaces were not in line with current guidance. Noted areas of concern in the treatment room included flooring, sinks, taps and plugs that were not in line with HTM 01-05 guidance, a carpeted area of flooring in the treatment room and work surfaces and cupboards where seals were either not in place or were broken. Unsealed surfaces, flooring and carpeted areas of the floor made it difficult to clean the treatment room in line with recommended guidance. We noted this had been identified in the previous infection prevention and control audits undertaken and as a consequence had repeatedly reduced the score and outcomes of the audits. Following the inspection, the practice provided an action plan of refurbishment for this treatment room. The provider should take action to ensure the suitability of the premises and ensure all areas are fit for purpose for which they are being used. In particular, ensure the treatment rooms flooring and work surfaces are in line with current guidance to ensure effective cleaning.

Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of clinical 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.

There was scope to improve the systems in place for the management of fire safety. Fire exits were clear and well signposted. A fire risk assessment had been undertaken by the practice, however, this had not assessed the potential risks of the overdue gas boiler servicing and the unsatisfactory and overdue electrical wire installation report.

The practice had systems for appropriate and safe management of medicines.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff.

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. There was scope to ensure these were documented and signed by staff.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. We were told the practice was in the process of recruiting additional dental nursing staff. Staff 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 was scope to improve the arrangements at the practice to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, 1-to-1 meetings, during clinical supervision, practice team meetings and ongoing informal discussions.

Staff stated 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.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned 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.

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

The equipment in use was maintained and serviced as per 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.