Clough 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. However, this was not fully reflected in our findings.

Staff had completed training in emergency resuscitation and basic life support every year. However, systems for checking emergency equipment and medicines were not effective as they had not identified that items of the medical emergency kit were missing or past their expiry dates.

The premises were visibly clean and free from clutter. Hazardous substances were clearly labelled and stored safely. However, we noted the electrical installation condition report was due to be completed in September 2024. This had not been done.

On the day of inspection, we noted the latest pressure vessel inspection test for the compressor was not available. We asked staff if this had been completed and they assured us it had. However, staff were unable to provide evidence of this. We were later sent evidence this had been completed after the inspection.

The practice had some arrangements to ensure the safety of the X-ray equipment. We asked to see evidence of local rules relating to the use of X-ray machines. Staff were unable to show us these. In addition, we noted there were recommendations on the latest routine test for the X-ray machines and it was advised to seek advice from the Radiation Protection Advisor. Staff were unsure if this had been done and were unable to provide evidence it had 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.

The practice managed fire safety well, and fire exits were clear and well signposted.

The practice had some systems for appropriate and safe management of medicines. A log was in place to monitor the use of NHS prescription pads. However, this system would not be able to identify if a prescription were to go missing.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. However, this was not consistently followed. We noted there was no evidence of immunity to Hepatitis B for 5 clinical members of 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 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 an effective system in place to assure themselves staff were up-to-date with required training. This included radiography, safeguarding and infection prevention and control.

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 annual appraisals, 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 had an 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. However, we noted that the recorded hot water temperatures were not routinely inline with their risk assessment and there was no evidence of this being actioned.

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. However, these were not completed every 6-months as required in national guidance.

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