Hillsborough Family Dental Centre

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, however, the only emergency medical oxygen cylinder on site was larger in size than guidance recommends. The cylinder held 2130Lt of medical oxygen and was not easily transportable if needed on the first floor in an emergency. The recommended size for a portable medical oxygen cylinder for a dental practice is 460Lt. We discussed this and provided feedback and managers assured us this would be addressed. 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, 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. We noted the specification of the compressor did not meet the Health Technical Memorandum (HTM 2022) – supplement 1, dental compressed air and vacuum systems and the Pressure Systems Safety Regulations (PSSR) and the Pressure Equipment Regulations (PER), as these apply to the provision of dental compressed air. We discussed this with the managers who sent confirmation after the inspection that the compressor had been replaced with a compliant unit. 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. We noted 1 treatment room had 2 entry points (doors); there was no system in place to safely control entry into this room during an X-ray exposure. We discussed this and provided feedback and managers assured us this would be addressed. 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.

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 annual appraisals, 1 to 1 meetings, 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. We noted there was no log/record kept to ensure any missed children’s dental appointments were followed up and kept track of under the ‘was not brought’ pathway. We discussed this and provided feedback and managers assured us this would be reviewed. 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, including for agency or locum staff. 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. 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 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 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. The external clinical waste receptacle was found to be unlocked when we checked it during the visit; supporting evidence was sent to us after the visit confirmed action had been taken to address this.

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