Ewood House Dental Surgery

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. Immediate life support training (or basic life support training plus patient assessment, airway management techniques and automated external defibrillator training) was also completed by staff providing treatment to patients under sedation. 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. However these were not effective.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Hazardous substances were clearly labelled and stored safely. Areas accessed by patients were visibly clean, uncluttered and well-maintained. We noted that the staff only basement area that included the decontamination room, office space and storerooms appeared cluttered and unkept. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Fire safety equipment was serviced and well maintained. However, on the day of the inspection the fire exit at the rear of the building was not clear, inhibiting exit in case of emergency. We were sent evidence immediately after the inspection that the obstruction had been removed.

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 practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available. The practice should improve the systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular relating to the management of fire safety. A fire risk assessment was carried out in line with the legal requirements. However, the risk assessment we were shown had not considered and mitigated all the risks associated with fire safety. Despite records being available to demonstrate staff carried out fire safety training, we could not be assured that the risk assessment had been completed by someone competent to do so. Immediately prior to our assessment, the practice had carried out an external fire risk assessment, and they were awaiting the report of findings. We were told any recommendations would be actioned. The practice carried out fire evacuation drills; however we discussed the importance of ensuring the building is evacuated promptly. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. Improvements were needed to ensure the risk assessments contained remedial or first aid actions for use in the event of an incident. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety and lone working. Improvements were needed to ensure all risk assessments were suitably adjusted to reflect the protocols in place and the practice environment. We noted the risks to staff using the stairs to carry heavy and awkward loads had not been considered and mitigated.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that currently there were sufficient staffing levels and when additional team members were needed, support could be obtained from a sister practice. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during appraisals, 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.

The practice had a recruitment policy and procedure to help them employ suitable staff. These reflected the relevant legislation. Improvements were needed to ensure these were effective. We looked at a number of staff files and from the records we were shown, we noted Disclosure and Barring Service (DBS) checks or appropriate risk assessments were not consistently carried out at the point of recruitment. Vaccination records were not available for all clinical staff members and the level of immunity to Hepatitis B had not been consistently checked following the completion of vaccination courses. Satisfactory evidence of conduct in previous employment was also not available for all staff members. 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, with the exception for those involved in the delivery of care under conscious sedation. Immediately after the inspection we were sent additional evidence of training, but we could not be assured the recommended number of hours of continued professional development training had been completed for each staff member in relation to sedation. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

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 followed infection control principles, including the use of personal protective equipment (PPE). Areas of the practice accessible to patients were visibly clean and there was a cleaning schedule in place. From the records we were shown, we noted the schedules were not consistently completed in full and there was no evidence these were reviewed. Improvements to the level of cleanliness could be made to some areas. We observed the decontamination of used dental instruments. Improvements were needed to ensure this was in accordance with recognised guidance. In particular: Containers used to transport instruments to and from the decontamination area were not clearly labelled. Not all transport containers were leak-proof, easy to clean, rigid and capable of being closed securely. Disposable non-linting cloths were not available to dry instruments. There was no foot-operated or sensor-operated clinical waste bin in the decontamination room. Immediately after the inspection we were sent evidence these had been ordered. We noted improvements were needed to the flow of instruments from dirty to clean through the decontamination processes and the current airflow arrangements in the decontamination room, to ensure these are in accordance with current guidance.

The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. The practice had infection control procedures which reflected published guidance. Improvements were needed to ensure staff adhered to guidance, including The Health Technical Memorandum 01-05: Decontamination in primary care dental practices, (HTM 01-05). An infection prevention and control audit was carried out in February and July 2024 with a score of 99% achieved in both cases. Improvements were needed to ensure this was completed accurately to drive the required improvements we observed on the day of the assessment. 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 carried out water temperature monitoring as part of the management of Legionella. However, where temperatures were outside the recommended parameters, we could not be assured prompt 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.