Thamesview 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 line 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 identified and managed most risks 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 broadly 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. Staff also participated in medical emergency scenario training.

The premises were visibly clean, well maintained and free from clutter. The provider held a list of substances hazardous to health (COSHH). Improvement was required to ensure hazardous substances were all risk assessed including safety data sheets and stored safely in line with the (COSHH) Regulations 2022. Following the inspection, the provider sent in evidence of completed risk assessments.

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 worked with the estates team to manage fire safety well, and fire exits were clear and well signposted.

The practice had systems in place for the safe management of prescribing. However, improved was required to ensure prescription pads were stored securely when not in use. Furthermore, there was no formalised process in place to monitor or track the use of prescriptions. This was addressed following the inspection.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, however, this was not consistently followed. Employment records for staff members identified several gaps. There was no documented evidence of conduct in previous employment, Disclosure and Barring Service (DBS) certificates were outdated for some staff members at the point of recruitment, and evidence of Hepatitis B immunity status (antibody titre levels) had not been obtained for all clinical staff. Following the inspection, the provider confirmed that these issues have been addressed.

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. The provider should consider implementing a formal system to monitor staff training to ensure these were readily available when required.

There were 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, during clinical supervision, practice team meetings and ongoing informal discussions.

One of the dentists was undertaking the Performer List Validation by Experience (PLVE) programme and received appropriate supervision from the principal dentist.

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. We saw areas of practice that were not consistent with HTM 01-05 guidance. For example, intraoral holders were not pouched, local anaesthetic cartridges were not blister-packed, 1 bin in the treatment room was not foot-operated, and sharps bins were not labelled at the time of inspection. The provider confirmed these had been addressed.

The practice worked alongside the health centre to develop 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. Improvements were required to ensure the difficult to reach areas of the practice, for example, behind the windows were cleaned regularly.

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.