Chester Road 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. 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.

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 the practice had the fire extinguishers serviced annually. The practice had some systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use. However, we saw the practice name and address was not included on the label for all dispensed medicines. Most emergency equipment and medicines were available. However, we observed on the day that the aspirin was not dispersible, and the child self-inflating bag and mask had expired in December 2024. The practice acted immediately and ordered all items required in the days following the assessment.

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. The management of fire safety required improvement. The practice could not provide any evidence a fire safety risk assessment had been carried out by a competent person and there was no evidence a fire drill had been conducted. However, staff were carrying out in-house fire testing of smoke alarms and torches. Once we highlighted this to staff, management acted immediately to address these omissions. They submitted evidence following the assessment that the fire safety risk assessment had been booked for the following week and the practice had conducted a fire drill. We were assured by the immediate response that the risk to safety was mitigated. Improvements must be made to ensure better governance of fire safety. The practice had arrangements to ensure the safety of the X-ray equipment. However, improvements were required to the oversight and assurance processes of radiation protection. We do not assess compliance with the Ionising Radiation regulations 2017 and the Ionising Radiation (Medical Exposure) regulations 2017 but we do request services to provide evidence that demonstrates their compliance to inform our findings. On the day of the assessment, some of the required radiation protection information was not available, such as routine performance testing of intra-oral X-ray machines. We also found actions from the critical examination for the handheld X-ray machine had not been completed. 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 and sepsis awareness.

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 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. During the on-site assessment, we reviewed 6 staff files. We noted that references were not consistently sought, and disclosure and barring service (DBS) checks were not consistently carried out by the practice prior to employment. We addressed this with management and were assured future recruitment would be in line with legislation. Improvements should be made to ensure oversight is maintained of completed staff training. On the day of assessment, we noted 2 staff members had not completed their safeguarding level 2 training in the last 3 years. The practice acted immediately and sent evidence all staff had completed safeguarding level 2 training in the days following the assessment. The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

We observed the decontamination of used dental instruments, which mostly aligned with national guidance. Improvements were required to ensure the water temperature during manual cleaning of instruments was monitored. 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.

The practice had infection control procedures which reflected published guidance and the equipment in use was maintained and serviced. Improvements were required to ensure rips in a dental chair were covered or repaired. The practice submitted evidence following the assessment that barriers had been ordered. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. Monthly hot and cold-water temperature checks were completed and logged. However, those seen were not always within the temperature ranges required by the risk assessment and this had not been identified by the practice. The practice acted immediately, turned the boiler temperature up and submitted evidence following the assessment that temperatures were in line with their risk assessment. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. 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 judgement for Medicines optimisation is based on the latest evidence we assessed for the Safe key question.