Stoke Lane Dentistry

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

Whilst 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.

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 had processes to identify and manage risks. However, improvements were needed to ensure these were effective. The practice had not considered the risks associated with lone working, sharps injuries and the processes in place to deal with these.

The practice had some arrangements to ensure the safety of the X-ray equipment. Not all the documentation relating to the X-ray equipment, including for the cone-beam computed tomography (CBCT), was available on the day of the inspection. The local rules for operating -X-ray equipment did not reflect the findings of the RPA in the pre-acceptance testing and feedback. A copy of the local rules was not available in designated areas. 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.

Improvements were needed to ensure fire safety was managed effectively. The new provider had commissioned a new fire risk assessment and was working through the recommendations made. However at the time of our inspection, there were no records of fire drills or emergency light testing.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

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 had systems for appropriate and safe management of medicines.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

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

Systems for overseeing staff training were not effective. Some individuals had completed training, including continuing professional development, shortly before the inspection, but there was no evidence that this training had been consistently maintained at the required intervals prior to that. Gaps in oversight meant up-to-date training records were not available for all clinical staff in relation to radiation protection.

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 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.

There were processes to support and develop staff, but staff told us these could be improved. The practice manager acknowledged this feedback and informed us of their plan to implement formal one-to-one meetings with all staff to discuss their learning needs and general wellbeing. We discussed the benefit of having regular practice team meetings, to share updates and information, for example recent relevant safety notifications from the Medicines and Healthcare Regulatory Agency (MHRA).

Historically staff had not always felt respected, supported and valued.

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. However, we observed that instruments awaiting reprocessing were not being kept moist, as recommended when there is a delay between use and sterilisation. 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 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.