Western Avenue 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.

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. Staff felt confident that risks were well managed at the practice, 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. We saw some records of servicing and validation of equipment in line with manufacturer’s instructions. Governance filing arrangements were haphazard so staff were unable to locate the written scheme of examination for the autoclave and the compressor. We saw evidence of this documentation following the inspection.– find out what was missing. 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. However, the practice could not locate the written scheme of examination for the autoclave and the compressor. They assured us that the examination had been carried out. They sent us confirmation of this shortly after the inspection. 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 provider could not locate it on the day of the inspection, however they sent us a copy of it immediately after the inspection. The management of fire safety was effective. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. 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 most risks to patient and staff safety. This included sepsis awareness and lone working. The practice did not have a sharps risk assessment in place and were not using safer sharps devices. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were being carried out.

At the time of our assessment, the patients felt there were enough staff working at the practice. They were able to book appointments when needed.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. The registered manager acknowledged that they felt there were challenges with not having sufficient staffing levels. They discussed with us the plans they had in place to address this, including a programme for recruitment in the coming months. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. We saw that the principal dentist was very supportive to staff, however the support was in an informal way with no structured or regular meetings with inexperienced or trainee staff members as would be expected in line with guidance. 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 did not fully reflect the relevant legislation. However, we saw that satisfactory evidence of conduct in previous employment and full employment histories had not been requested for any members of staff. Disclosure and Barring Service (DBS) checks had not been obtained by the practice for some staff. An application for the appropriate level of DBS check was arranged immediately following the inspection. At the time of the inspection the practice did not have a dedicated practice manager or a qualified nurse. The principal dentist was carrying out the majority of the practice management duties and was supervising the trainee dental nurse. They were also the only dentist working in the practice. Whilst the staff in the practice were effective the practice were not able to demonstrate that there were enough qualified staff to ensure effective running of the practice. We discussed this with the principal dentist and they told us that they were in the process of trying to recruit more staff members to the team to address the capacity concerns. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Newly appointed staff had a structured induction, and clinical staff completed continuing professional development required for their registration with the General Dental Council. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals.

Patients told us that the practice looked clean, and equipment appeared to be in a good state of repair.

Staff told us how they ensured the premises and equipment were clean and well maintained. They demonstrated knowledge and awareness of infection prevention and control processes. Staff told us that single use items were not reprocessed.

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 broadly aligned with national guidance. However, there was only one sink in the decontamination room (with no separate bowl for scrubbing), and the demonstration was not fully in line with guidance. Some dental items, such as cotton wool rolls, in draws were not covered and exposed to aerosol contamination. We also observed instruments with cement in pouches that were sealed and stamped as cleaned.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Staff had appropriate training, and the practice completed infection prevention and control (IPC) audits in line with current guidance. Actions identified from audits in January and May 2024 had not been implemented. The practice explained that this was due to staff capacity issues. They assured us that the actions would be reviewed as a priority. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had policies and procedures in place to ensure clinical waste was segregate in line with guidance. Clinical waste was stored in a locked bin but not kept in a secure area. We discussed this with the practice, and they made arrangements for it to be secure the following day.

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