Clarendon Dental Spa

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 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.

The practice had processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety. Staff felt confident that risks were well managed at the practice. However, this was not always reflected in our findings.

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 we saw evidence the majority of staff had completed training in emergency resuscitation and basic life support every year. We received evidence following the inspection that staff members without evidence of training had booked basic life support training. Systems for obtaining evidence of continuing professional development should be improved.

Staff providing treatment to patients under sedation had completed further life support training (ILS) and continuing professional development.

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.

A critical examination report for the cone-beam computed tomography (CBCT) machine was obtained and sent after the inspection. This highlighted recommendations which had not been acted on in a timely way. The practice manager provided assurance that they were seeking the advice of their Radiation Protection Advisor to action any outstanding recommendations, and these would be addressed and rectified.

The documentation of fire safety management could be improved. Fire exits were clear and well signposted. However, we highlighted the external health and safety risk assessment, dated 7 November 2024, highlighted a fire compartmentation breach requiring action within 3-months. On the day of inspection, staff were unable to tell us whether this had been addressed. Following the inspection, we have been assured it had been addressed.

Evacuation of sedated patients was covered in a policy but had not been practised in evacuation procedures scenario training. We were told staff checked fire extinguishers monthly. However, the recording of these checks could be improved.

The practice should take action to implement any recommendations in the practice's health and safety risk assessment and ensure ongoing fire safety management is effective.

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 procedures that reflected relevant legislation. However, the policy and procedures were not always followed and did not always provide sufficient oversight.

We reviewed 21 staff files on the day of inspection and 15 did not have a Disclosure and Barring Service (DBS) check carried out at the point of recruitment. The certificates we were provided with were either outdated and required renewing or carried out after the start date. One clinical staff member had a basic DBS check rather than the required enhanced check.

There was no evidence of satisfactory conduct in previous relevant employment for 14 members of staff. Following the inspection, we were provided with some references. However, the majority were contact details of referees, but no evidence they had been contacted at the point of recruitment.

The practice should ensure their recruitment policy and procedures are followed to ensure accurate, complete and detailed records are maintained for all staff.

There were no records of satisfactory immunity to hepatitis B or a risk assessment available on the day for 8 clinical staff members. We received evidence of immunity for 5 staff members in the days following the inspection and the practice confirmed that blood tests were booked for the remaining staff members.

The practice should take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

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 told us that there were sufficient levels of 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 processes to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. However, these were not always followed and there was a lack of oversight of training.

Mandatory topics had not been completed by all staff members. We raised this with the practice and training was either booked or completed in the days following the inspection.

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, 1-to-1 meetings, practice team meetings 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 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 aligned with national guidance. We saw, and staff confirmed that single-use items were not reprocessed. We highlighted there should be a system in place to track the use and processing of implant drill bits. This was implemented immediately after the inspection.

The practice mostly 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. However, some hot water temperatures recorded were out of range and staff had not raised this with management to be addressed. We raised this with staff and this has been addressed.

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.

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