Ashcroft 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.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. The first aid kit contained a number of bandages which had expired. Since our visit we have received evidence to confirm this shortfall has been addressed. The premises were visibly clean, well maintained and free from clutter. Hazardous substances used at the practice were clearly labelled and stored securely. Risk assessments had been completed but corresponding safety data sheets were not available. We noted that although secure, a number of hazardous substances were stored on high shelving in the cleaning equipment cupboard which could result in accidental exposure. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Improvements were needed to the management of fire safety. In particular, the emergency lighting, battery operated smoke detectors and fire alarm manual call points were not tested appropriately. Six staff had not completed fire safety training in the previous 12 months and a fire safety risk assessment was carried out by someone who could not demonstrate competency in the management of fire safety. Since our visit we have received evidence to confirm that all of these shortfalls have been addressed. Radiation warning signs were not present on treatment room doors. Since our visit we have received evidence to confirm this shortfall has been addressed. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. 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, which included safeguarding. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals, but improvements were needed. In particular, 3 staff did not have evidence to confirm they carried out safeguarding children training, 2 staff did not have evidence to confirm they carried out infection prevention and control and radiography training and 1 staff member staff did not have evidence to confirm they carried out safeguarding vulnerable adults training. Annual basic life support (BLS) training was overdue for 6 staff. Since our visit we have received evidence to confirm that outstanding training has been carried out for all relevant staff. There were effective processes to support and develop staff with additional roles and responsibilities. Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. They 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 stated they felt respected, supported and valued, and they were proud to work in the practice. Staff discussed their training needs during annual appraisals and practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development.

The practice had infection control procedures that reflected published guidance. This included procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had cleaning procedures in place to ensure effective cleaning. Improvements could be made to ensure that cleaning standard checks were recorded appropriately. Staff demonstrated knowledge and awareness of infection prevention and control processes. However, we saw that some instruments were stored unpackaged in treatment rooms. Since our visit we have received evidence to confirm that x-ray holders are packed individually. Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. The equipment in use was maintained and serviced as per manufacturers’ instructions. We saw, and staff confirmed that single use items were not reprocessed. Non clinical waste bags were used to line clinical waste bins in treatment rooms. This may cause confusion for staff carrying out clinical bin emptying tasks. Staff manually cleaned dental instruments prior to being sterilised. A heavy-duty glove and long handled replacement protocol was not in place. Impression trays were rinsed in a treatment room handwashing sink. We noted the sanitary bin in the patient wheelchair accessible toilet was not specific to a wheelchair user’s requirements. The practice completed infection prevention and control audits in line with current guidance. Improvements were needed to ensure that the floor surfaces in the treatment rooms were complete and impervious. Since our visit we have received evidence to confirm these shortfalls have been addressed.

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