Abbeydale Dental Care Centre-Sheffield

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.

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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff we spoke with told us that equipment and instruments were well maintained and readily available. The provider described the processes they had in place to identify and manage risks, and the reporting of risks was encouraged. Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained.

The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. The practice ensured the facilities were maintained in accordance with regulations. A fire safety risk assessment was carried out in line with the legal requirements. The management of fire safety was effective. We highlighted that fire drills should be documented. The practice had some arrangements to ensure the safety of the X-ray equipment. Not all of the required radiation protection information was available. We saw a recommendation to obtain advice from their radiation protection adviser about the direction of the primary beam for the X-ray machine in a new surgery that we were not assured had been acted on. There were gaps in one of the routine reports demonstrating these weren’t always carried out at the appropriate intervals. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety, sepsis awareness and lone working. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out, but these were ineffective, documented justifications to prescribe were not in line with nationally accepted guidance from the College of General Dentistry.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during annual appraisals, 1 to 1 meetings, during clinical supervision, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. Staff we spoke with demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the relevant legislation but were not followed. Two staff files had no evidence of essential checks having been carried out at the point of employment. Evidence of Hepatitis B immunity and current indemnity were not obtained consistently for clinical staff. Some of the references were not appropriate for the roles individuals were in. The practice ensured clinical staff were qualified and registered with the General Dental Council. Newly appointed staff told us they had a structured induction, but this could not be evidenced. Systems were not in place to review and ensure staff were up to date with their mandatory training and their continuing professional development required for their registration with the General Dental Council. We saw the practice had processes to support and develop staff with additional roles and responsibilities.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Staff should ensure validation testing of the ultrasonic cleaner was carried out in line with national guidance. We saw the results of recent testing to ensure the ultrasonic cleaner effectively removed soils had failed, but staff had marked this as a pass which showed misunderstanding. We were not assured that testing of the autoclave included thermometric testing to demonstrate this device met the test parameters. The manager confirmed this would be addressed and rectified. Staff demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. Staff completed infection prevention and control (IPC) audits in line with current guidance. The most recent audit highlighted handwashing facilities should be installed in the decontamination room. The practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. The Legionella risk assessment was not up to date with the current water systems in the building. As a result, we identified 2 new ‘dead legs’ created by recent changes (dead legs are altered, abandoned or capped sections of water piping systems that water cannot flow through). The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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