Denchic Dental Spa

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.

Observation Emergency equipment and medicines were readily available. Staff told us they checked the emergency medicines and equipment, however, there was no recorded evidence of this. We saw that a spacer device for the administration of Salbutamol, the child-size self-inflating bag with reservoir and 3 sizes of clear face mask were missing and the adult-sized self-inflating bag with reservoir had exceeded its expiry date. The missing and out of date equipment was ordered immediately after the inspection and a weekly check log for emergency medicines and equipment was implemented. Aspirin was not of the recommended formulation. Glucagon (a medicine used to manage low blood sugar) was stored in a fridge but the records we were provided showed that the temperature of the fridge was checked only monthly. On the day of our visit, the fridge temperature recorded was 55 degrees Fahrenheit which is above the manufacturer’s recommended temperature for storage of this medicine. The premises were clean, well maintained and free from clutter. However, cleaning products were stored in an unlocked cupboard which was accessible to patients. This was not in line with Control of Substances Hazardous to Health (COSHH) Regulations 2002. We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions. However, there were no records to show that the ultrasonic bath was regularly serviced. Immediately after the assessment we were sent evidence that a service of the ultrasonic bath had been arranged for August 2024 to coincide with servicing of the autoclaves. Fire exits were clear and well signposted, and fire-fighting equipment was serviced and well maintained. We saw records of regular periodic in-house testing of smoke alarms and fire evacuation drills at the practice and that staff had completed annual fire awareness training. However, we did not see evidence that the fire-detection equipment had been serviced.

The practice had not ensured the facilities were maintained in accordance with regulations. We were not provided with evidence that the practice had obtained a satisfactory electrical installation condition report. We were advised this had been booked for the day following the inspection although have not been provided with a copy of the report. An in-house fire safety risk assessment had been completed by the principal dentist. We did not see any evidence of additional fire safety training to demonstrate they had the qualifications, skills, competence and experience to perform this task. X ray equipment was serviced, and safety tested on 25 June 2024, although some remedial works were still outstanding. On the day of inspection some required radiation protection information was not available. In particular, registration with the Health and Safety Executive (HSE) for the use of ionising radiation and local rules were not available. Following the inspection, HSE registration was completed. The practice had completed risk assessments to minimise the risk that could be caused from substances that are hazardous to health for dental products but had not included general cleaning products. Additionally, staff did not have access to chemical safety data sheets. The practice had implemented some systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety, sepsis awareness and lone working. However, risks assessments were generic in that they referred to safer sharps which were not used in the practice and not person specific for example, the cleaner who worked alone in the practice. 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 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 members told us “always welcomed my feedback and ways to improve the service”,” I am happy to be part of this team”. Staff told us that there were sufficient staffing levels. 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. However, on the day of the assessment we did not see records for 2 members of staff to show us that they had completed training in safeguarding for children and vulnerable adults and 1 clinical member of staff had not completed training to the appropriate level for their role. Staff completed training to the appropriate level immediately after the inspection.

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. However, we saw that satisfactory evidence of conduct in previous employment was not requested. 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. We saw that tests were undertaken to validate the cleaning process of the ultrasonic bath retained the capability of removing protein. However, other tests to validate the efficacy of the cleaning process of the ultrasonic bath were not completed ie foil testing. This is not in line with the recommendation of Health Technical Memorandum 01-05: Decontamination in primary dental care dental practices. Foil tests to use for validation of the efficacy of cleaning for the ultrasonic bath were ordered immediately after the inspection.

The practice had infection control procedures which mostly reflected published guidance and the equipment in use was maintained and serviced with the exception of the ultrasonic bath. Staff had appropriate training. The practice completed infection prevention and control (IPC) audits every six months although these were not effective as they did not reflect the processes at the practice ie they referred to the use of a washer disinfector. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems which included treatment of the dental unit water lines, water quality testing and monthly temperature checks. However, we saw that some recommended actions from a risk assessment completed by an external company in 2022 were identified as still outstanding in the most recent assessment undertaken immediately before the inspection. This included removal of a dead leg pipework and the heating boiler quick filling loop left attached and flexible hose potential for back flow have not been addressed. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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