Dolphin Dentalcare

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 accordance with the relevant regulations.

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 in relation to sharps safety and sepsis awareness effectively. However, we saw that improvements were needed to ensure that a practice specific fire risk assessment was carried out and reviewed annually, and that the ongoing fire actions were completed.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and but this was not wholly reflected in our findings.

A fire safety risk assessment, specific to the dental practice, was not carried out in line with the legal requirements. A fire risk assessment was carried out by the building owner, but this did not adequately cover the dental practice or refer to the additional risks associated with a dental practice. In addition, the practice relied on the building owner to record the weekly testing of the fire alarm, and monthly checks of the emergency lighting and fire extinguishers and did not maintain their own records of checks. Following the inspection, we received evidence a fire risk assessment for the practice had been arranged, and assurance that the practice would take ownership of the checks and testing of the fire equipment within the practice. Fire exits were clear and well signposted.

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.

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

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 had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely; however, improvements were underway to the systems in place to track and monitor their use.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation but were not always being followed.

For example, we were not shown evidence of Hepatitis B immunity (titre levels) or a risk assessment for 3 staff members; a Disclosure and Barring Service (DBS) check was not available for 1 staff member, and no associated risk assessment had been carried out. A full employment history and satisfactory evidence of conduct in previous employment was not available for any staff members; satisfactory information about any physical or mental health conditions was also not available for any staff.

Newly appointed staff did not have evidence of an appropriate role specific structured induction.

Staff 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. However, the information displayed of who to escalate concerns to externally did not contain contact details.

The practice did not have arrangements to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. Not all clinical staff were able to demonstrate that they had undertaken all CPD relevant to their roles as recommended by the General Dental Council (GDC).

We saw gaps in the following mandatory and recommended topics: fire safety, safeguarding adults and children, IR(ME)R (Ionising Radiation (Medical Exposure) Regulations), infection prevention and control (IPC), Learning Disability and Autism, Legionella, legal and ethical, Mental Capacity Act, sepsis, and complaints handling.

There were ineffective processes to support and develop staff with additional roles and responsibilities. Staff told us they discussed their general wellbeing during ongoing informal discussions and practice meetings, but their learning needs, and aims for future professional development were not documented in annual appraisals or one-to-one meetings.

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

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

The practice had ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment in line with current guidance, was not available to evidence that the associated risks had been assessed, and that appropriate control measures and recommendations were in place. Following the inspection, we received assurance that improvements were being made to the practice’s processes and an external contractor had been arranged to carry out a risk assessment.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. However, the clinical waste bins in 1 surgery were not appropriate and a cytotoxic bin was not available for the disposal of cytotoxic waste. We received evidence following the inspection that the surgery bins, including for cytotoxic waste, had been replaced, and the waste contract updated.

The practice had infection control procedures that reflected published guidance but were not always being followed.

The practice completed infection prevention and control (IPC) audits, but these were not reflective of practice or in line with current guidance. For example, audits were not completed at recommended intervals and did not include action plans.

Staff demonstrated knowledge and awareness of IPC processes, but not all had received appropriate training.

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.

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.