South Bar 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 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.

The practice identified and managed risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and this was reflected in our findings.

Staff had access to emergency equipment and medicines, which were checked in accordance with national guidance. Staff demonstrated an understanding of how to respond to medical emergencies and had completed annual training in basic life support and emergency resuscitation. However, the medical emergency kit was stored within a locked cupboard, which could potentially delay access to emergency equipment and medicines in the event of an emergency. During the inspection, we found that the Glucagon contained within the emergency kit had expired three months previously. The provider took immediate action to mitigate the risk and provided evidence that a replacement had been ordered.

Staff involved in sedation procedures had not completed the required life support training in line with current guidance. This meant the provider could not demonstrate that all relevant staff were appropriately trained to respond to a medical emergency. Following the inspection, the provider acted promptly and provided evidence that the required training had been booked for all relevant staff. The provider also confirmed that no sedation sessions were planned until staff had completed the training, which reduced the immediate risk to patients.

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. This included cone-beam computed tomography (CBCT).

The practice did not always manage fire safety effectively. Fire exits were clearly signposted; however, the practice had not carried out fire drills, which meant there was limited assurance that staff knew what actions to take in the event of a fire. Following the inspection, the provider submitted evidence that a fire drill had been completed and confirmed that fire drills would be carried out regularly going forward.

The practice had systems in place for the appropriate and safe management of medicines. However, we found that dispensing labels applied to antibiotics did not include the practice's details, which was not in line with requirements. The provider took immediate action following the inspection and provided assurance that this had been rectified.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. However, these procedures were not always followed. We found that records for two members of staff did not contain evidence of their qualifications. There was no evidence of Hepatitis B immunity status for one clinical staff member. Following the inspection, the provider submitted evidence confirming that the staff member was a Hepatitis B non-responder and had completed the appropriate declaration.

In addition, one staff member's personnel file did not contain evidence of an induction, and another staff member's file did not include a curriculum vitae (CV). This meant the provider could not always demonstrate that all required pre-employment checks had been completed and appropriately documented.

The practice ensured clinical staff were 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.

The practice ensured 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 annual appraisals and practice team meetings and ongoing informal discussions.

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. Staff confirmed that single-use items were not reprocessed.

The practice had procedures in place to reduce the risk of Legionella and other waterborne bacteria developing within water systems, in line with a risk assessment and current guidance. Hot and cold water temperature monitoring was undertaken. However, records showed that hot water temperatures were below the recommended threshold of 55°C, and there was no evidence that appropriate action had been taken to investigate the cause or implement remedial measures.

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

Equipment was maintained and serviced in line with 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.