Leven Vale Dental Practice Also known as Leven Vale DP Ltd

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.

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 some risks effectively, as described by staff, including sepsis awareness and lone working. However, improvements were required in relation to infection prevention and control, hazardous substances, clinical waste, stock control and environmental cleaning.

The governance and oversight of environmental cleaning was not managed effectively. We saw the communal areas of the practice to be visibly unclean. Improvements were required to the cleaning and maintenance of the practice. Ensuring that environmental cleaning schedules were consistently followed and that the practice was clutter free.

Hazardous substances were clearly labelled. However, improvements were required to ensure hazardous substances were stored correctly and not accessible to patients.

We saw most records of servicing and validation of equipment in line with manufacturer’s instructions. However, there was no evidence available to demonstrate that the fire detection system had recently been serviced. The provider has since submitted evidence to show a service has been completed after the inspection day.

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).

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 practice managed fire safety well, and fire exits were clear and well signposted.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, improvements were required. We noted 1 staff member had not undergone a disclosure and barring service (DBS) check. The practice assured us this was now underway. Inductions were not always completed for all locum staff and there were no risk assessments for staff who had not completed or had no evidence of the titre levels for Hepatitis B status. The provider has since sent evidence that these risk assessments are now in place.

Staff feedback was obtained through meetings and informal discussions. Staff did not always feel concerns they raised were addressed in a timely manner. Concerns were raised in previous months regarding staffing levels and a perceived lack of management presence, which was also highlighted during the inspection.

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 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 ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

Improvements were required to the infection control procedures to ensure they reflected published guidance. In particular, we noted there were un-pouched instruments stored in boxes that had not been sterilized in line with published guidance and pouched instruments in surgeries that were not dated to demonstrate when they had been processed.

There were ineffective systems for stock control. We noted some materials were out-of-date.

The practice’s protocols to ensure safe segregation and disposal of hazardous waste were not always working effectively. In particular clinical waste was not always disposed of correctly and clinical waste sacks were not being stored securely prior to collection.

The practice protocols to ensure effective cleaning needed improving. We noted damage to bench tops within multiple clinical areas which were unable to be cleaned and clinical areas were cluttered and visibly unclean, including handwashing sinks, surgery floors and behind units within the surgeries.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. However, during manual cleaning, the correct ratio of solution to water was not being measured.

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.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance. However, this was not a reflection of what we found on the day of the inspection.

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