Elm Park 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 risks, however, there were certain areas which should be strengthened. For example, the lone working risk assessment for the dental hygienist did not adequately reflect the specific risks associated with staff working without chairside support.

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. However, this was not fully stocked in line with current guidance. Missing items were ordered and replaced immediately. Staff we spoke with 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. However, not all hazardous substances and products had been risk assessed and safety data sheets were not consistently retained or readily accessible to staff. Improvements have been made following the inspection.

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. This included cone-beam computed tomography (CBCT).

The management of fire safety at the practice was well managed for most parts. We observed that fire exits were clear and well signposted. However, we noted that at the time of the inspection servicing had lapsed for the fire alarm, emergency lighting and the air conditioner units; these were satisfactorily addressed following the inspection.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely; however, a process was not in place to monitor and track their use. This was implemented immediately after 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. We did not see evidence that Schedule 3 information had been fully obtained and maintained for all relevant staff. This included documentary evidence such as right to work status, full employment history, conduct in previous employment/s, checks with disclosure and barring service (DBS) and evidence of immunity level through titre levels. We received evidence following the inspection that these had 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. However, improvement was required to ensure all clinical staff received training to the required level 2 including the safeguarding lead.

The system in place to monitor and oversee completion of mandatory staff training including continuing professional development needed improving to ensure training records were kept up-to-date and reviewed at the required intervals.

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.

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 procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, the provider should ensure that recommendations are actioned in a timely manner.

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.