• Dentist
  • Dentist

Bridge Dental Practice

Court Street, Leamington Spa, Warwickshire, CV31 2BB (01926) 426232

Provided and run by:
Dr. Surbjeet Matharoo

Report from 13 August 2024 assessment

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Safe

Regulations met

Updated 6 November 2024

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.

Learning culture

Regulations met

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

Safe systems, pathways and transitions

Regulations met

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

Safeguarding

Regulations met

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

Involving people to manage risks

Regulations met

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

Safe environments

Regulations met

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. Logs to demonstrate cleaning completed were recorded on a wipe clean board. There was therefore no historical evidence to demonstrate cleaning had been completed. On the day of assessment, the premises were 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. Fire exits were clear and well signposted. All fire safety equipment was serviced and well maintained apart from emergency lighting. Monthly in-house checks were being completed; however the emergency lighting had not been subject to annual servicing. The electrical installation condition report (EICR) recorded an unsatisfactory outcome with some urgent actions for completion. Following this assessment we were sent a copy of an EICR completed on 16 October 2024 showing that the necessary actions had been completed and a satisfactory outcome achieved.

The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. However, there was scope to ensure the practice facilities were maintained in accordance with regulations. The provider had carried out an internal fire risk assessment which had identified some issues for action which had not been acted upon. The risk assessment did not identify other fire safety risks such as an unsatisfactory outcome on the EICR or information regarding staff fire safety training. There was scope for improvement regarding systems in place introduced regarding the management of fire safety. The practice had arrangements to ensure the safety of the X-ray equipment and the majority of the required radiation protection information was available. The 3 yearly performance check for the Orthopantomograph (OPG) was not available on the day of assessment. A copy of a certificate demonstrating a performance check had been completed after this assessment was forwarded within 48 hours. 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.

Safe and effective staffing

Regulations met

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Although staff appraisals had not been completed, we were assured that these were to be scheduled in going forward. We saw that monthly 1 to 1 meetings were held and staff stated that they felt respected, supported and valued and were proud to work in the practice. Staff discussed their training needs during these 1 to 1 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. Staff told us they had received a structured induction programme, which included safeguarding.

The practice had a newly implemented recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. We were told that as a result of implementation of the procedure the practice identified that Disclosure and Barring Service checks (DBS) had not been completed for all staff. Some DBS checks were completed many years ago and checks were outstanding for 5 staff including the trainee dental nurses. All staff had therefore recently either applied for or renewed their DBS checks, some staff had signed up to the annual update service. Although the practice had evidence to demonstrate that all staff had received relevant vaccinations, they did not have evidence that 5 staff were immune to hepatitis B. 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 recently introduced systems to try and ensure that staff training was up-to-date and reviewed at the required intervals. The practice was unable to confirm that staff had completed all recommended training. We were sent evidence to demonstrate that training had been completed by some staff following this assessment in relation to safeguarding adults and children, fire safety and infection prevention and control. Training was outstanding for some staff regarding fire safety, safeguarding adults and children and learning disabilities and autism awareness but we were assured that staff were scheduled to complete this training. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

Infection prevention and control

Regulations met

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. The log to demonstrate cleaning had been completed was on a wipe clean notice board. The practice did not have historical records and was therefore not able to demonstrate cleaning tasks completed previously. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. The practice did not provide a sanitary waste bin in the patient toilet. We were assured that a bin would be made available as soon as possible. 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 demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. Staff had appropriate training and the practice completed infection prevention and control (IPC) audits in line with current guidance. 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 segregated and stored appropriately in line with guidance.

Medicines optimisation

Regulations met

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