Dentexcel - 8 Angel Court

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.

Staff could access emergency equipment and medicines and they had completed training in emergency resuscitation and basic life support. However, some emergency medicines and equipment were missing or damaged, and the practice's checks had not identified this. This meant the practice could not demonstrate it was fully prepared to respond to some medical emergencies. The practice took immediate action to address these issues following inspection feedback.

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. While the inspection team saw that the compressor had been serviced regularly they were not provided with a written scheme of examination, which is a document used to help ensure the equipment remains safe to use.

The practice had arrangements to ensure the safety of the X-ray equipment and most of the required radiation protection information was available. This included cone-beam computed tomography (CBCT). Following feedback from the inspection team, the practice ensured they had notified the Health and Safety Executive (HSE) that they worked with radiation generators. 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. Systems for monitoring fire safety were not fully effective. Although responsibility for fire safety was shared with the building management company, the practice did not keep records of its own checks of fire safety equipment. Monthly checks of emergency lighting and fire extinguishers had not been recorded in line with the practice fire risk assessment, and the practice could not demonstrate that all staff had completed the fire safety training required.

The practice had systems for appropriate and safe management of medicines. Improvements were required to the medicines log, so that the medicines stored on site could be effectively tracked and monitored.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, the practice did not have effective systems in place to ensure clinical staff had adequate immunity to Hepatitis B.

The practice did not ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. The inspection team were unable to review training records for all staff members on the day of our inspection. Following our inspection, the practice shared training records for nursing and reception staff. These showed that 3 out of 16 staff members had completed safeguarding training appropriate to their role, 1 out of 16 staff members had up to date fire safety training and 1 out of 16 staff members had received training in learning disabilities and autism.

However, staff knew how to escalate safeguarding concerns within the practice and externally and were aware of how safeguarding information could be accessed.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions. Staff told us that the practice provided them with lunch and learn courses which covered a variety of topics.

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 felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “My role to the practice is recognised and appreciated.” Another staff member said, “I have been given many opportunities to learn and try new things to develop.”

The practice had infection control procedures that broadly reflected published guidance. Staff 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. Clinical waste was stored within a storage cupboard. On the day of our inspection, the lock for this cupboard was not working. The practice assured the inspection team that this would be fixed. In addition, the practice evaluated the frequency of waste collections, to see if they were sufficient for the volume of clinical waste generated by the practice.

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

The practice completed infection prevention and control audits in line with current guidance. Improvements could be made to the audits by ensuring they help identify and drive areas of improvement.

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