Coptfold 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. We noted that this was not confirmed by evidence during the assessment. 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. We found this was not fully confirmed by evidence during our inspection.

Emergency equipment and medicines were mostly available and checked in accordance with national guidance. There was no dispersible aspirin and daily checks of the medical fridge temperatures where not recorded. We noted a number of items that had exceeded the expiry dates and were stored along with in date items. We discussed this with the provider, immediately following the inspection the practice confirmed they had put systems in place to declutter the emergency equipment and medicines, replace any missing items and monitor the fridge temperatures. 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 mostly well signposted, however there was scope to increase signage from the first floor and stairwell. 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 electrical installation report undertaken in 2020 was marked as unsatisfactory, there was limited evidence of the completion of any recommended actions. Immediately following the inspection the practice contacted their external provider and were taking actions to resolve those items not completed. Portable appliance testing had not been undertaken since October 2020. A fire safety risk assessment was carried out in line with the legal requirements. There were no logs of staff training, fire drills or regular testing of smoke alarms. Immediately following the assessment the provider confirmed the fire risk assessment would be reviewed with the intention to implement simple emergency lighting as recommended in the previous risk assessment. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was mostly available. However, the local rules were last signed 2021 and not all recommendations from last radiation performance report had been reviewed or actioned. Following the inspection the provider confirmed they were reviewing these actions. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. There was scope to ensure these included all household items used in the practice. 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 not carried out.

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 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. 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. There was scope to improve the practice 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.

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. Infection prevention and control (IPC) audits were not completed in line with current guidance. The provider offered assurances these would be updated. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. We identified scope for improvement in ensuring that completion of monitoring checks for water temperature and flushing of seldom used outlets was recorded accurately. Following our inspection, the provider submitted evidence of updated recording systems and processes. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. However, we noted no sanitary waste bins were available in the practice toilets.

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