South Ealing 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.

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 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 practice had 2 medical emergency kits as they sometimes carried out domiciliary visits and would take a kit with them.

Staff providing treatment to patients under sedation had completed basic life support (BLS) training rather than the required immediate life support (ILS) training which covers advanced airway management. We discussed this with the registered manager who has confirmed that ILS training is booked in March.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, there was no evidence of current, or historical portable appliance testing (PAT) certificates.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included handheld X-ray equipment. However, the Cone-beam computed tomography (CBCT) machine had not been included on the radiation risk assessment. We discussed this with the registered manager and following the inspection have received evidence that this is being addressed.
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.

The practice did not manage fire safety effectively. A fire risk assessment, completed by an external company on 28 November 2020 listed multiple recommendations that had not been actioned. The risk assessment stated “There is no fire-alarm system installed within the premises. There are only two single point detectors present. Single point detection is not appropriate for this type of premises and will not provide the level of protection or reliability needed.” There were 12 recommendations, 11 of which were classified as requiring remedial action as soon as possible.

We did not see evidence of fire alarm servicing. We saw in-date service certificates for emergency lighting and fire extinguishers, however, in-house testing was not completed or documented. Fire drills were carried out but were not documented and did not consider evacuation of sedated patients.

Following the inspection, we have received confirmation that actions from the fire risk assessment are being in the process of being addressed, and that in-house checks of fire equipment are being carried out and documented.

Fire exits were clear and well signposted.

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, the policy was not fully adhered to. We reviewed 8 staff files. There were no references on file for most staff members. Hepatitis B titre levels (to indicate immunity) were not available for 5 out of 8 staff members. Disclosure and Barring Services (DBS) checks had been completed, however, several staff had basic checks rather than the enhanced check required for clinical staff.
Since the inspection, we have received evidence that new DBS checks at the correct level are in progress, and blood tests to check Hepatitis B immunity have been booked for those without evidence.

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 ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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 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.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. However, clinical waste bins were accessible to the public and were not locked or tethered.

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.