Lichfield Family 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 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 processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety.

The provider should improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular, all risk assessments including those for Legionella management are reviewed to ensure they cover all areas of the practice, and that fixed electrical installation inspections are carried out in accordance with recognised guidance.

We drew the attention of the provider to two areas that required review. The Legionella risk assessment and schematic drawing was not accurate. This meant that sentinel points for hot and cold water testing may not be accurate. The provider put steps in place to mitigate this risk immediately following inspection, confirming that they would flush all outlets whilst refurbishment work was ongoing. Assurances were provided that when the refurbishment work on the practice was completed, a new Legionella risk assessment will be carried out and this will identify the new sentinel points for staff.

Staff were unable to provide certification in relation a fixed electrical wiring inspection. The practice have taken steps to mitigate risks in this respect by having a new consumer unit (formerly known as a mains board) fitted and inspection and certification of safety for this was produced. Assurances were provided that a full electrical safety certificate will be available once refurbishment work is completed.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. 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 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 management of fire safety was effective, and fire exits were clear and well signposted.

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, including agency or locum 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 we spoke with had the skills, knowledge and experience to carry out their roles. 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 arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff were given opportunities to discuss their learning needs, general wellbeing and aims for future professional development.

Staff stated they felt respected and supported and were happy 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.

We observed use of personal protective equipment and the decontamination of used dental instruments, which aligned 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. We drew attention to areas we identified for improvement in this area and the provider responded immediately to mitigate risk and confirmed a new, full Legionella risk assessment would be carried out once refurbishment work was completed.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

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.