Acorn 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.

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, sepsis awareness and lone working.

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.

Most emergency equipment and medicines were available. Items that were missing or did not display an expiry date were ordered following our inspection. We found improvements were required with monitoring the equipment in line with national guidance.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We identified improvements were required with Control of Substances Hazardous to Health (COSHH) risk assessments and safety data sheets to ensure they were available for staff for all materials and cleaning products.

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 however, we found the local rules required updating. This was updated during our inspection. 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 ensured fire safety equipment was serviced and fire exits were clear and well signposted. At the time of our inspection were reviewed a basic fire safety risk assessment that was carried out by the provider. Following our inspection, the provider carried out a more comprehensive risk assessment which included an action plan to address shortfalls identified.

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

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff.

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 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.

The practice did not have information available to staff and there was limited knowledge in relation to ‘Was Not Brought’ procedures to monitor vulnerable adults and children. Staff we spoke to did not know how to make a safeguarding referral or who to inform if they had concerns. A policy and procedure was produced following our inspection.

The practice had some systems in place to monitor staff training, including continuing professional development.

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, clinical supervision, practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were happy to work in the practice.

The practice had infection control procedures that mostly reflected published guidance. We found some instruments were not pouched as per guidance and some out of date dental materials. We also noted a damaged operators chair in 1 surgery which would inhibit adequate cleaning.

Staff received 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 some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. We were not provided with a Legionella a risk assessment and found actual hot and cold water temperatures were not recorded to ensure they were within the recommended temperature range.

The practice had minimal protocols to ensure effective cleaning of the practice. Following our inspection, a daily cleaning schedule was implemented.

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

The practice completed infection prevention and control audits however, we found it did not reflect practice procedures. During our inspection a new audit was carried out.

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