Imperial Dental - Stroud

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 to identify and manage risks. Staff demonstrated an open culture around safety. However, our findings highlighted areas for improvement in relation to risk oversight and management.

The practice had some arrangements to ensure the safety of the X-ray equipment. However, quality assurance checks were not effective, as they had failed to identify damage to the sensor used to capture x-ray images. In addition, there was no evidence that staff authorised to use the equipment had reviewed the relevant safety information, and recommendations from critical examination reports had not been 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.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency. However there was limited evidence that staff were up to date with their annual training in emergency resuscitation and basic life support.

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

There was a lack of effective oversight of equipment servicing and premises maintenance, with no clear system in place to ensure that repairs and recommended actions were implemented and monitored.

As part of the infection prevention and control (IPC) procedures, the practice would benefit from a scheduled deep cleaning programme, as there was no evidence of regular environmental cleaning of areas such as window sills, skirting boards, and radiators.

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

The practice managed fire safety well, and 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.

Staff had the skills, knowledge and experience to carry out their roles. The practice was undergoing a period of significant recruitment, with staff from other practices within the group providing cover.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

While the practice had a recruitment policy and procedures that reflected relevant legislation, these were not always effectively implemented to ensure the safe recruitment of staff, including agency or locum staff. Improvements were needed to the recruitment system to ensure that key protocols, such as staff induction, were consistently completed in line with requirements.

The practice did not have systems in place to effectively oversee staff training. There was insufficient evidence of a robust, signed-off induction process for all staff, and no system to ensure that mandatory, refresher, or continuing professional development (CPD) training was completed at the required intervals. A large volume of training had been completed following the announcement of the inspection, but previous training records were not available for all staff, limited the assurance that training had been consistently maintained over time.

While staff demonstrated some awareness of safeguarding and how to escalate concerns, there was insufficient evidence of a robust safeguarding policy and procedure to protect people from abuse or neglect. There were inconsistencies in the levels and timing of safeguarding training completed by staff, and a lack of clarity around the designated safeguarding lead, with conflicting information between the policy and staff responses.

Staff reported a positive and supportive team environment, stating that they work well together. However, some concerns were raised about the lack of an immediate practice manager, with staff expressing uncertainty about leadership presence, direction, and how their feedback would be acted on. These concerns were discussed with the leadership team, who acknowledged there were ongoing challenges and confirmed they are working hard to address them.

The practice had infection control procedures that reflected published guidance and staff had recently completed appropriate training on infection prevention and control processes.

The practice completed infection prevention and control audits in line with current guidance, however timescales for completing improvements where not documented or fed back to staff to effectively drive improvement.

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