Wimpole Dental Office

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.

Whilst there are issues to be addressed, the impact of our concerns relates to the governance and the oversight of the risks, rather than a patient safety risk.

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 had completed training in emergency resuscitation and basic life support every year. We found that knowledge of medical emergency management could be improved, and staff would benefit from further training and practicing medical emergency scenarios. Following the on-site assessment the provider submitted evidence that they had booked further in-person medical emergency training for staff.

Staff we spoke with told us that equipment and instruments were well maintained and readily available.

The practice had some systems in place to reduce the risk of fire. The fire extinguishers within the practice had been serviced and annual fire evacuation drills were being carried out.

We were provided with the practice fire risk assessment dated 9 June 2024. We were not assured that this was carried out by a person who had the qualifications, skills, competence and experience to do so. The risk assessment failed to adequately assess key factors to reduce and mitigate risk. Following the on-site assessment, the provide told us that they had requested a quote for an external fire risk assessment.

The practice did not have an electrical installation condition report, following the on-site assessment, the provider told us that this had been booked for 5 February 2025.

Most emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. On the day of assessment clear facemasks for the self-inflating bag and a spacer device were not available. The practice took immediate action and placed an order for the missing items.

We saw satisfactory records of servicing and validation for the autoclave and compressor in line with manufacturer’s instructions.

Hazardous substances were clearly labelled and stored safely. However, the practice did not carry out risk assessments for all hazardous substances used and safety data sheets were not available to staff.

The practice had some arrangements to ensure the safety of X-Ray equipment. However, the radiological equipment survey report dated 16 March 2023 included some outstanding actions that had not been addressed.

The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sepsis awareness and lone working. The sharps risk assessment needed improvements to clearly identify all types of sharps used and the specific safety measures in place at the practice.

The practice had systems for appropriate and safe management of medicines. Improvements could be made to ensure the antimicrobial prescribing audit was carried out, aligned to the current guidance and included an analysis of trends and findings to drive improvement.

Staff we spoke with had the skills 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. Improvements were needed to ensure appraisals covered 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 to help them employ suitable staff. This reflected the relevant legislation. However, the policy was not always followed. On the day of assessment not all recruitment documentation, including Disclosure and Barring Service (DBS) check, full employment history and proof of identity were available for review. In addition, we were not assured that the provider had requested the required documentation for temporary staff. Following the on-site assessment the provider submitted some of the missing documentation. We noted that some of these had been requested from staff after our on-site assessment. Improvements were needed to ensure that recruitment checks are carried out at the point of employment in line with the relevant legislation.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

There were no records to show that newly appointed staff had received a structured induction to prepare them for their new role.

The practice had some arrangements to ensure staff training was up-to-date and reviewed at the required intervals. However, not all staff completed training in autism and learning disability awareness, fire safety, legionella and safeguarding. Following the on-site assessment the provider submitted evidence to demonstrate that staff had now completed training in these topics.

We saw the practice had effective processes to support and develop staff with additional roles and responsibilities. For example, the dental nurse also carried out compliance and practice management related duties.

The practice appeared visibly clean.

The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

We observed the decontamination of used dental instruments, which aligned with national guidance.

Staff followed infection control principles, including the use of personal protective equipment (PPE).

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 some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. However, the management of risks associated with Legionella was not always effective. A water risk assessment dated 26 October 2022 was made available for review. This had been carried out by the landlord of the building and did not cover Legionella safety measures within the parameters of the practice and did not identify and include control measures specific to a dental setting. In addition, the practice did not have a written scheme of control for water management. The practice had carried out monthly water temperature checks. We noted that the temperature measurements were not always within the required range. However, the practice could not demonstrate that action had been taken to address this issue.

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