Manor Lodge 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 effective care in accordance 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.

Staff demonstrated an open culture in relation to people’s safety.

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

Staff could access emergency equipment and medicines. However, staff had not checked these in line with national guidance and checks carried out were not effective. We saw expired items and airway management equipment that had been repackaged, which meant the practice could not ensure the integrity of the equipment. We have received confirmation from the practice that this has been rectified.

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

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 identified and managed risks and staff described the processes. However, these processes were not always effective. Sharps risks were not fully identified and a risk assessment we saw did not reflect current practice.

The practice did not have effective arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was not available. This included for the cone-beam computed tomography (CBCT). However, the arrangements to ensure the safety of the radiation equipment were not working effectively. There were local rules, but these were not reflective of current practice and were not readily available.

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.

Fire exits were clear and well signposted. Improvement was needed to the governance and oversight of fire safety, in particular, documentation of equipment checks, staff training and servicing of the alarm system.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff.

Staff felt respected, supported and valued, and they were proud to work in the practice.

The practice ensured all clinical staff were qualified and registered with the General Dental Council. However, they did not ensure all clinical staff had appropriate professional indemnity cover. We did not see evidence that a dentist providing implant treatments had appropriate indemnity insurance.

Newly appointed staff had an appropriate role specific structured induction.

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 did not always ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. We saw gaps mainly in fire safety training and learning disability and autism awareness.

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

The practice had protocols to ensure effective cleaning.

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

The practice completed infection prevention and control audits in line with current guidance.

The practice's infection prevention and control procedures were not always followed effectively. We found that mops were not stored in a manner that allowed them to dry fully between uses. This could increase the risk of bacterial growth and cross-contamination.

Improvement should be made to the practice's waste handling protocols to ensure waste is segregated and disposed of in compliance with the relevant regulations, and taking into account the guidance issued in the Health Technical Memorandum 07-01. This was discussed with the practice, and we were assured that a new system would be implemented immediately.

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