West Earlham Dental Health 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.

We saw satisfactory records of servicing and validation of 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.

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

The practice had processes to identify and manage some risks. We identified concerns with the risk assessments for and management of fire, electrical safety, emergency medicines and equipment, legionella, sharps safety and the control of substances hazardous to health (COSHH).

A fire risk assessment had been completed in December 2024. However, multiple high-risk actions were still outstanding. Following this feedback, some actions were completed, yet some still remained. Smoke alarms and the emergency lighting present in the building had not been routinely tested. The practice told us that testing will now commence and will be recorded.

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) 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.

Staff could access emergency equipment and medicines that were checked in line with national guidance. However, we saw the checks carried out by the practice had not identified that that the adult defibrillator pads had expired, and there were no paediatric defibrillator pads. Immediately following the inspection, we saw that these had been purchased. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Whilst a sharps risk assessment had been completed, it was not reflective of the processes in the practice. Following feedback, the Infection Control Policy Statement had been updated, but this did not meet the requirements of a risk assessment. A risk assessment must identify specific sharps-related risks, reflect current procedures, and outline control measures.

The premises was visibly clean, well maintained and free from clutter. The practice told us plans were in place to refurbish and modernise the practice.

Hazardous substances were clearly labelled and stored safely. However, not all manufacturer safety data sheets (SDS) were available. Improvements must be made to the practice’s processes to ensure risk assessments are undertaken, as identified by the Control of Substances Hazardous to Health Regulations 2002. Following the inspection, the practice told us that the folder was in the process of being updated.

While these issues were present, our concerns relate to lack of governance and risk oversight, rather than immediate patient and staff safety.

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. Following this feedback, the practice gave assurance that this shortfall would be rectified.

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. However, improvements were required to ensure safeguarding information was available around the practice with important contact information. Following the inspection, we saw that this information had been updated and was now readily available. Staff knew how to escalate safeguarding concerns within the practice.

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 ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. Monthly hot water temperature checks were often below recommended levels, and this had not been addressed. Following feedback, the practice contacted a plumber to investigate. Improvements were required to ensure that actions were taken when water temperature checks were out of range.

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.