Southbrook 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. Whilst there are issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the provider has taken action to address the shortcomings, the likelihood of them occurring in the future is low.

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 provider described the processes they had in place to identify and manage risks. However, improvements must be made to these processes to ensure these risks are appropriately managed. Emergency equipment and medicines were available. However, we noted some items of the kit could not be easily located on the day of assessment. In addition, some needles, syringes and oro-pharyngeal airways had passed their expiry date, and this had not been identified by the checking process. The glucagon was also stored in the fridge, but the temperature was not monitored to ensure it remained within the required parameters. We raised these issues on the day of assessment and the out-of-date items were ordered immediately. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. The premises were clean, well maintained and free from clutter. Staff we spoke with told us that equipment and instruments were well maintained and readily available. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. 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, and we saw some recommendations from this had been acted on. For example, installing additional fire detectors. However, we noted regular checks were not being carried out on fire detection or firefighting equipment, no fire training had been undertaken by staff and no fire drills had been completed. We highlighted the importance of ensuring recommendations in the fire risk assessment are implemented. For example, access to emergency lighting. The practice had some arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was not available. We highlighted areas where radiation protection adviser’s feedback should be sought to update the radiation protection file and local rules specific to the equipment in use and the controlled zone. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. Hazardous substances were clearly labelled and stored safely. However, we noted the blood and mercury spillage kits had expired. We raised this with staff and new kits were ordered on the day of assessment. Improvements must be made to the systems to assess, monitor and manage risks to patient and staff safety. These included sharps safety as the sharps risk assessment did not reflect methods used within the practice and staff awareness of the risks associated with sepsis could be improved. We discussed this on the day of assessment and were assured it would be addressed and rectified. The practice had some systems for the appropriate and safe handling of medicines. However, improvements could be made to the stock control system for antibiotics which were stored on site.

Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during 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. There was no recruitment policy available on the day of our assessment. We identified gaps in the recruitment process for current staff and saw clinical staff who had worked at the practice within the previous 3 months had not had essential checks carried out. These included lack of evidence of appropriate vaccinations and Hepatitis B titre levels, registration with the General Dental Council and professional indemnity. The provider submitted evidence of these documents for the current staff after the on-site assessment. The practice did not have effective formal processes to support and develop staff and ensure their training was up-to-date. On the day of assessment there was limited evidence to show staff had completed required training. The provider submitted evidence after the on-site assessment of training that staff completed after the assessment. We were told by staff that they had a structured induction, which included safeguarding. However, there was no documented evidence to support this.

The infection control procedures displayed did not reflect the most up-to-date published guidance. Despite this, staff demonstrated knowledge and awareness of infection prevention and control processes. We observed the decontamination of used dental instruments, which aligned with national guidance, and we saw single-use items were not reprocessed. We highlighted that pouches of sterilised instruments should be marked with the date for reprocessing. The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. The equipment in use was maintained and serviced. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. The practice had procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. However, we noted the infrequently used outlets were not flushed on a regular basis, water temperatures were not being recorded and staff had not completed Legionella awareness training as recommended by the risk assessment.

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