Balsall Common 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. A discussion was held regarding the storage of medical emergency kit to ensure that staff could access these in a timely way. There was scope for improvement to the frequency of checks made to ensure compliance with national guidance. The provider was aware of this and gave assurances that the frequency of checks and access to the kit, would be amended immediately. 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, although not all exits were well signposted, servicing and maintenance of fire safety equipment had recently been introduced.

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. The provider had carried out an internal fire risk assessment which had identified some issues for action. For example, the electrical installation condition report was overdue, this had been booked for 19 October 2024 and we were told that visual checks of portable electrical appliances would be completed going forward. An external professional was scheduled to complete another fire safety risk assessment on the 30 September 2024, in line with the legal requirements. Effective systems had recently been introduced regarding the management of fire safety. We were not shown any evidence to demonstrate that fire drills had been completed although we saw that 6 fire drills had been scheduled for 2025. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT). We saw that electromechanical servicing of the X-ray machinery was scheduled to take place on 26 September 2024. 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 sepsis awareness and lone working. Sharps risk was included in the practice’s health and safety risk assessment. The health and safety risk assessment reflected procedures used at the practice regarding sharps. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were 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. 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 ongoing informal meetings and practice team meetings. During these meetings staff were able to discuss learning needs, general wellbeing and aims for future professional development. The provider confirmed that staff appraisal systems were in place, but appraisal meetings were overdue. We were told that appraisals had been scheduled for all staff during 2024. 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 recruitment policy and procedure to help them employ suitable staff. Amendments had recently been made to ensure these reflected the relevant legislation. 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. Staff were sent reminders when training was due for completion. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

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. The cleaning log documented the cleaning that had been completed on a daily and weekly basis but did not clearly demonstrate which specific areas in the practice had been cleaned. We were told that a separate log would be made available for the areas of the practice to demonstrate cleaning completed. The dental chair cover in surgery 2 was ripped, we were assured that a replacement seat cover had been ordered. 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 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. We were told that a legionella risk assessment had taken place at the practice some time ago. There was no legionella risk assessment on the premises, however, a further risk assessment had been booked. We saw that records were available to demonstrate that monitoring of water temperatures was being completed as required. 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.