Durley Avenue Dental Practice

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 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 had some processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff felt confident that risks were well managed at the practice, but this was not wholly reflected in our findings. Staff demonstrated an open culture in relation to people’s safety.

Emergency equipment and medicines were available and checked in accordance with national guidance and staff could access these in a timely way. However, checks had not identified that the automated external defibrillator’s (AED) battery needed replacing. In response to our feedback, a new battery was ordered. Staff knew how to respond to a medical emergency, but not all staff had completed training in emergency resuscitation and basic life support every year.

The premises were visibly clean and well maintained, but the decontamination room had cluttered surfaces, and the flooring and sink seals were not intact. We received evidence of the resealed sinks following the inspection.

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. This included cone-beam computed tomography (CBCT) X-ray equipment. At the time of inspection, the practice was not registered with the Health and Safety Executive (HSE) for working with radiation. The practice addressed this immediately. 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.

A fire safety risk assessment was carried out in line with the legal requirements. However, recommendations within this had not all been actioned, including installing a fire detection system and fire doors. In addition, it was not clear which risk assessment was being followed as a further 2 fire risk assessments had been carried out internally. In response to our feedback, the practice told us they had arranged for these points to be actioned.

The practice had ineffective systems for appropriate and safe management of medicines. We did not see a log in place to monitor and track their use. Following the inspection a log was created to use going forward.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, but this was not always being followed. Information relevant to staff employment in their role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was not always available. For example, a Disclosure and Barring Service (DBS) check was not seen for 1 staff, and 2 staff held a DBS from a previous employment with no associated risk assessment. Satisfactory evidence of conduct in previous employment was not seen for 2 staff, evidence of Hepatitis B immunity was not available for 4 staff, and there was no risk assessment in place for staff with a low response to the vaccine.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. However, the practice had ineffective 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 topics: Ionising Radiation (Medical Exposure) Regulations (IRMER), fire safety, safeguarding adults and children, medical emergencies and basic life support (BLS), infection, prevention and control (IPC), learning disability and autism, Legionella, Sepsis and complaints handling.

Improvements were underway to enhance practice protocols and procedures to ensure staff were up to date with their mandatory training and their CPD.

There were ineffective processes to support and develop staff with additional roles and responsibilities. Staff told us they discussed their learning needs, general wellbeing and aims for future professional development during informal discussion, but did not have appraisals or 1 to 1 meetings.

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 stated they felt respected, supported and valued, and they were proud to work in the practice. They told us that there were sufficient levels of 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 had infection control procedures that reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned with national guidance, however there was insufficient dilution of the detergent used for cleaning instruments. Immediate action was taken to address this. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had completed a risk assessment to reduce the risk of Legionella, or other bacteria, developing in water systems; however, we were not assured that this had been completed by a competent person who has the knowledge, experience, and ability to identify and manage Legionella risks in a specific water system.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. At the time of inspection hand-operated bins were in use in the decontamination room and 1 surgery. These have since been replaced with foot-operated bins.

The equipment in use was maintained and serviced as per 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.