Fernleigh 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 sepsis awareness and lone working. The practice did not consistently follow its sharps management policy, which states that sharps must be dismantled by the clinician and disposed of at the point of use, and must not be transported to the decontamination room. This was brought to the provider’s attention, and immediate action was taken to ensure that contaminated sharps were now disposed of safely at the point of use.

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 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. Staff also participated in medical emergency scenario training.

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.

The practice had some systems in place to manage fire safety. Fire exits were clear and well signposted and fire extinguishers were serviced regularly. The practice also carried out periodic in-house fire safety checks and fire evacuation drills were conducted twice a year.

A fire risk assessment had been completed in October 2023 and was reviewed annually. However, we noted that a recommendation to install emergency lighting in line with British Standards had not been actioned. In response to our inspection feedback, the practice manager advised that enquiries would be made regarding the installation of appropriate emergency lighting. Further improvements should be made to ensure that in addition to internal fire safety checks, the fire alarm system is serviced at appropriate intervals by a competent person.

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 procedure to help them employ suitable staff. These broadly reflected relevant legislation. On the day of the inspection, recruitment documentation for the visiting prosthodontist was not available for review. Following the on-site assessment, the provider submitted the missing documentation. Improvements should be made to ensure the practice obtained the required recruitment documentation, including satisfactory evidence of conduct in previous employment, for all new members of staff before commencing employment.

We identified that a member of staff had received two primary doses of the Hepatitis B vaccination; however, there was no evidence that immunity had been confirmed. Following the inspection, the provider submitted a risk assessment for staff who were non-responders or had incomplete vaccination status.

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.

The practice had systems in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, we found this was not consistently followed. On the day of the inspection, not all members of staff had evidence of training in core subjects including safeguarding, interacting with people with a learning disability and autistic people, fire safety, Mental Capacity Act and radiography. In response to our inspection feedback, the provider submitted the majority of the outstanding training certificates in these core subjects. Improvements to the systems were required to ensure that all role-specificcoretraining is completedin a timely manner, kept up to date, and that any gaps are promptlyidentifiedand addressed.

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, one-to-one meetings and practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice. One staff member told us, “This is a very good place to work. Everyone supports and helps each other, which creates a positive environment.”

The practice had infection control procedures that broadly reflected published guidance, however, we identified some gaps. Sterilised instruments were not consistently transferred to the designated clean storage box immediately after processing. In addition, sterilised instruments kept within the decontamination room were at risk of exposure to aerosol contamination. The box used to store sterilised instruments was cluttered, which made it difficult to retrieve instruments without risking cross contamination. We discussed with the provider and highlighted the need for a more robust system to ensure that the clean-to-dirty flow within the decontamination process is maintained at all times. In response, the provider took immediate action and implemented an improved process, including ensuring that instruments were pouched promptly upon removal from the autoclave.

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 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. Improvements could be made to ensure that electrical equipment testing was carried out in a timely manner so that portable appliances remained safe to use.

The practice completed infection prevention and control audits in line with current guidance. Improvements should be made to strengthen audits to identify and address gaps, in particular in relation to the storage of sterilised instruments.

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