Whelby Dental

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.

Although there are issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk.

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 providers processes for identifying and managing some risks such as dental radiography, medical emergencies, Legionella and fire risk management required strengthening. Staff described the processes for sharps safety, sepsis awareness and lone working.

Staff demonstrated an open culture in relation to people’s safety. Areas we found needing improvement were acted on immediately.

Staff were not checking medical emergency equipment and medicines in line with national guidance. Weekly logs and check sheets were not in place, and the system for checking emergency drugs required strengthening, as missing and out of date items within the emergency kit had not been identified. Oxygen cylinder checks had also not been undertaken. Following the inspection the provider submitted evidence confirming that the required items had been ordered and that effective weekly checklists had been implemented.

Staff stored Glucagon (a medicine which helps to raise blood glucose levels) in the fridge; however, the fridge temperatures were not being monitored in line with manufacturers guidance. Following the inspection the practice leader sent confirmation that fridge temperature logs had been put in place.

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, well maintained, we noted treatment rooms and decontamination room surfaces were cluttered making effective cleaning difficult. We noted the inside of drawers in treatment rooms were not clean. Hazardous substances were clearly labelled, but were not stored securely. Following the inspection the practice leader sent confirmation that these had been put in place.

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

The practice arrangements to ensure the safety of the X-ray equipment required strengthening as not all the required radiation protection information was available. There were no records to confirm the 3 yearly performance checks had been carried out or that the electromechanical servicing of the X-ray units had been completed annually. When asked, local rules were not available. These were later presented however did not show named staff who were qualified to take X rays. Following the inspection the practice leader sent confirmation of servicing and updated local rules displayed in treatment rooms.

We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings.

Fire exits were clear and well signposted. However, procedures for managing fire safety required strengthening. We found internal checks of smoke alarms, emergency lighting and fire drills had not been carried out. Following the inspection the practice leader sent confirmation that these had been put in place.

The practice had some 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.

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.

The practice had some processes to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, there was no evidence of training for radiography for the clinicians.

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, one-to-one meetings, clinical supervision, 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 mostly 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. However, there were no logs for the weekly changes of brushes or heavy-duty gloves. Checklists of equipment performance were not always completed and not signed, there was no accountability when staff were absent.

The practice procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance required strengthening. Hot and cold-water checks had not been reaching the recommended temperatures, remedial action had not been taken to address them at the time of the inspection. Water quality checks were not being carried out, we were told water samples had been sent for Legionella testing, but had not been returned.

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; however, these were carried out annually rather than 6 monthly which is not in line with current guidance.

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