Horsford 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 accordance with the relevant regulations and had taken into consideration appropriate guidance.

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.
 

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.

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

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff 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.

The practice had processes to identify and manage some risks. We identified concerns with the risk assessments for and management of fire, legionella, sharps safety and the control of substances hazardous to health (COSHH).

We noted there had been a sharps injury, and although the incident was followed up, it was not formally discussed or documented to support learning and improvement. The practice must implement an effective system for investigating and reviewing accidents, incidents, and significant events to prevent recurrence and drive improvement. Following the inspection, the practice reported that staff received additional training and that sharps would now only be removed by the dentist.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. However, manufacturer data sheets were not available for all hazardous materials. Improvements should be made to the practice’s processes to ensure risk assessments are undertaken, as identified by the Control of Substances Hazardous to Health Regulations 2022. Following the inspection, the practice told us that the missing data sheets will be added to the folder.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available.

The practice had several fire safety issues, including a fire risk assessment that had been carried out by a person who was not able to demonstrate competency to do so. Whilst the fire alarms had been serviced, routine testing for alarms and emergency lighting were not being completed. Following the inspection, a certified fire risk assessment was arranged, and the practice confirmed that regular testing and documentation would be implemented.

While these issues are present, our concerns relate to governance and risk oversight, rather than immediate patient and staff safety.
 

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. Improvements could be made to ensure that the policy was always followed. Following the inspection, the practice told us that the policy will be reviewed and requests for evidence of conduct in previous employment will be documented.

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 we spoke with had the skills, knowledge and experience to carry out their roles. 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 have comprehensive arrangements in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Following this feedback, the practice told us that staff training will be reviewed and discussed with staff. The practice should implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.

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 ongoing informal discussions.

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

The practice had infection control procedures that generally reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

We observed use of personal protective equipment and the decontamination of used dental instruments, which generally aligned with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had some procedures in place to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. Monthly hot water temperature checks were consistently below recommended levels and not addressed. Following feedback, the practice increased the boiler temperature, committed to ongoing monitoring, and arranged a new Legionella risk assessment.

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

The equipment in use was maintained and serviced as per manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance. However, improvements should be made to ensure the audit is reflective of the procedures taking place in the practice.
 

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