Kirkholt Dental Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was providing well-led care in accordance 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 Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The provider had updated policies and procedures to support staff to identify and manage risks. We saw the governance and oversight of risk in relation to medical emergency arrangements, fire safety, recruitment procedures and radiation protection had been improved.

Checks on medical emergency equipment were now in accordance with national guidance.

A system was in place to identify when equipment was due for servicing. We saw the dental compressor had a pressure vessel inspection and service caried out and these were satisfactory.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. Recommendations in previous equipment reports had been reviewed and the radiation protection advisor’s advice sought. Risk assessments were in place and the local operators’ rules had been updated to ensure X-ray equipment was not directed towards unprotected windows during use.

The day-to-day management of fire safety was effective, and fire exits were clear and well signposted. Staff carried out safety checks of equipment which was serviced regularly. A new fire risk assessment had been carried out, and the recommendations actioned or risk assessed.

The practice had updated their recruitment policy and procedures to reflect relevant legislation, and to ensure that appropriate checks were completed prior to new staff commencing employment at the practice. This included obtaining suitable identification, right to work and Disclosure and Barring Service (DBS) checks. The practice ensured clinical staff held current registration with the General Dental Council and appropriate professional indemnity cover.

Further action should be taken to obtain evidence of the effectiveness of Hepatitis B vaccinations for 4 clinical staff members. The manager highlighted barriers to accessing testing for staff which we urged them to raise in the locality to find solutions. Risk assessments were in place for staff where the effectiveness was unknown.

The induction process for new staff had been updated to ensure this was completed, appropriate and role specific.

Improvements had been made to the systems to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Staff had received fire safety, safeguarding and appropriate radiography and radiation protection update training. In addition, staff in lead roles were provided with clear information and training to support them in their duties. We highlighted further areas for review, including ensuring staff received training on sepsis recognition, Legionella, autism and learning disability awareness.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. Protein residue testing was now carried out and documented to ensure the efficacy of the washer disinfector.

We saw the practice now received and acted on safety alerts. A log was in place to maintain a record of alerts received and reviewed.

There were effective processes for investigating incidents and accidents. We saw a recent sharps incident had been followed up appropriately, and there was evidence of investigation and learning to prevent reoccurrence. A procedure had been introduced to ensure only the dentists were permitted to handle and dispose of needles to minimise the risk of inoculation injuries to staff.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.