Illume Smiles - Queens Road

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.

Staff could access emergency equipment and medicines that were checked in line with national guidance. Aspirin was present in the emergency kit, but it was not dispersible.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

The security of the emergency medicines trolley required attention to remove the risks of unauthorised interference.

Staff providing treatment to patients under sedation completed immediate life support training.

The premises were visibly clean, well maintained and free from clutter.

Control of Substances Hazardous to Health (COSHH) applicable cleaning products were stored in the staff kitchen and toilet areas. These areas were neither secure nor labelled appropriately in line with COSHH regulations.

A blood and bodily fluid kit expired in June 2024.

The practice had arrangements to ensure the safety of the intraoral X-ray equipment, and the required radiation protection information was available.

The practice also had a cone-beam computed tomography (CBCT) x-ray machine. An electro-mechanical, safety, and calibration check and 3 yearly radiation safety and image quality assessment was carried out in April 2024. Monthly quality assurance tests, also known as phantom tests, were not available which indicated that an annual radiation safety and image quality assessment was required.

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.

Improvement was needed to the management of fire safety. Specifically, equipment checks, staff training and fire drills.

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 but improvement was needed. Health assessments were not routinely completed for new staff as part of their recruitment process.

Improvement was needed to ensure induction records were completed in full for both employed and locum staff.

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

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.

Improvement was needed to ensure that 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 discussed their learning needs, general wellbeing and aims for future professional development during practice team meetings and ongoing informal discussions.

Improvement should be made to ensure that performance reviews are carried out for self-employed clinicians.

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 effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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

Equipment was serviced in line with manufacturers’ instructions.

Staff were unable to evidence that they had oversight of the standard of cleaning carried out by an external cleaning company.

Two chairs used in clinical areas had damaged covers which made effective cleaning a barrier.

Clinical waste was stored outside the practice. We noted that a second (non-clinical bin) was used to store excess waste when the clinical waste bin was full.
This storage arrangement did not meet clinical waste storage and COSHH labelling requirements.

Improvement could be made to the current storage arrangements of sharps bins used in treatment rooms. Specifically relating to the height of bin location (above knee and below shoulder).

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