The Hollies 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 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 premises were visibly clean. 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 identified and managed some risks. We identified concerns with the management of fire and electrical safety, emergency medicines and equipment, and radiography.

The practice had not ensured that the facilities were maintained in accordance with regulations, as there had not been an Electrical Installation Condition Report (EICR) since 2018, to ensure the electrical system and wiring in the building was safe. Following this feedback, we saw that an electrician had been scheduled to carry this out.

We saw that the gas boiler had been serviced after the announcement of this inspection, but it had not been routinely serviced in the past.

A fire risk assessment had been completed in November 2006. However, some actions were still outstanding. Following this feedback, the practice told us that a new fire risk assessment had been arranged. Improvements should be made to ensure that any actions arising from a risk assessment are carried out in a timely manner.

Staff could access emergency equipment and medicines that were checked in line with national guidance. However, we saw that multiple items were missing which had not been identified in the routine checks carried out. Following our feedback, the missing items were ordered. Improvements must be made to ensure that the checks of the emergency equipment and medicines were effective so any missing items were identified. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff also participated in medical emergency scenario training.

The practice had some arrangements in place to ensure the safety of the X-ray equipment. However, we saw that one intra-oral radiography unit, which was in current use, had not been routinely serviced. Following this feedback, we saw that this was arranged. Additionally, neither radiograph unit had had annual electromechanical checks completed. 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 had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, improvements were required to ensure that all staff had sufficient immunity to hepatitis B or an associated risk assessment.

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 did not have a comprehensive process in place to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. We found that not all required staff had evidence of radiography and radiation protection training.

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.

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

The practice completed infection prevention and control audits, yet these were not in line with current guidance as they were completed annually. Following this feedback, the practice told us they will now be carried out on a 6 monthly basis.

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