Pitsmoor Dental Health Centre

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. The provider had made improvements in relation to the regulatory breach we found at our inspection on 6 March 2024.

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. 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.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. The premises were clean, well maintained and free from clutter. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained.

The provider confirmed the provision of conscious sedation had ceased permanently at the practice. The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. A fire safety risk assessment was carried out in line with the legal requirements. The management of fire safety was effective. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. The practice had systems for appropriate and safe handling of medicines, however, we noted the process to help monitor and track dispensed medicines could be improved. We found the stock control of dispensed medicines was ineffective and medicine pack labelling was not in line with current guidance. Antimicrobial prescribing audits were carried out. Referrals to external dental or healthcare professionals were centrally monitored to ensure they are received in a timely manner and not lost. The dental care records we reviewed reflected the minimum standards required in guidance. We noted improvements could be made to ensure verbal consent and treatment options were more consistently recorded.

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.

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.

Staff demonstrated knowledge and awareness of infection prevention and control processes.

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. Staff had appropriate training, and the practice completed Infection prevention and control (IPC) audits in line with current guidance. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. 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.