• Dentist
  • Dentist

New Square Dental Surgery

35 New Square, Cambridge, Cambridgeshire, CB1 1EZ (01223) 506492

Provided and run by:
Dr Monica Bhardwaj

Report from 25 July 2024 assessment

On this page

Safe

Regulations met

Updated 17 December 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. Immediate life support training (or basic life support training plus patient assessment, airway management techniques and automated external defibrillator training) had not been completed by all staff providing treatment to patients under sedation. The practice told us that sedation would not be carried out again until all members of the sedation team had completed immediate life support training in line with guidance, and following the inspection we saw that training for an additional staff member had been arranged. 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.

Most emergency equipment and medicines were available. Improvements could be made to ensure that the emergency kit included all medicines and equipment necessary, as advised in guidance from the Resuscitation Council UK. Following the inspection, we saw that all missing items had been ordered and received. These were checked in accordance with national guidance. Staff could access these in a timely way. 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. A fire safety risk assessment was carried out in line with the legal requirements. We saw that whilst actions had been carried out, these had not been documented. Following the inspection, we saw that this was now completed. The practice had arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was not available during the inspection, but was sent to us the following day. 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. Improvements could be made to ensure clinicians followed the relevant guidance for antimicrobial prescribing. Following the inspection, we were told that these will be reviewed and adhered to in the future.

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. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during annual 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, including for agency or locum staff. These reflected the relevant legislation. Improvements could be made to ensure that all staff had evidence of their Hepatitis B status following immunisation or a risk assessment had been completed. Following the inspection, we saw that arrangements had been made for blood tests to be carried out. 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.

Infection prevention and control

Regulations met

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 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. However, improvements could be made to ensure that outstanding actions were completed and documented. 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.