3 Step Smiles 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.

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.

The practice had some processes to identify and manage risks and staff we spoke with were able to describe these to us. Staff demonstrated an open culture in relation to people’s safety.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

The practice had systems for appropriate and safe management of medicines.

We saw satisfactory records of servicing and validation of most equipment in line with manufacturer’s instructions.

The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health. However, improvements were required to ensure safety data sheets were retained and first aid measures were documented within the risk assessments.

Improvements were required to the systems to assess, monitor and manage risks to patient and staff safety. In particular, sharps safety and lone working. The practice acted immediately and submitted evidence of new sharps and lone working risk assessments in the days following the inspection.

Most emergency equipment and medicines were available. However, the systems for checking the medical emergency kit were ineffective as they had not identified that some items were missing or not stored appropriately in line with The Resuscitation UK guidance. The practice acted immediately and ordered all items required in the days following the inspection.

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 inspection, some of the required radiation protection information was not available. The Cone Beam Computed Tomography (CBCT) machine, a machine used in dentistry to create detailed 3D images of the teeth, jaws and surrounding areas, was overdue its annual routine performance test. The practice provided evidence this was booked for May 2025.

The management of fire safety was not always effective. Fire exits were clear and well signposted, the practice had ensured a fire risk assessment has been conducted by a competent person and fire detection equipment was serviced in line with their risk assessment. However, there were outstanding recommendations from the fire risk assessment from July 2024 and the practice were not conducting and documenting monthly in-house testing of the emergency lighting and monthly visual inspections of fire extinguishers. We highlighted this with staff and were assured this would be addressed urgently. Improvements must be made to ensure better governance of fire safety.

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

Newly appointed staff had an appropriate role specific structured induction.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during practice team meetings and ongoing informal discussions.

Staff stated they felt respected, supported and valued, and they were proud to work in the practice.

The practice had a recruitment policy and procedures that reflected relevant legislation. However, these were not consistently followed. During the inspection, we reviewed 7 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 were required to ensure oversight is maintained of completed staff training. On the day of inspection, we noted 4 staff members had not completed their safeguarding training in the last 3 years. The practice acted immediately and sent evidence all staff had completed safeguarding training in the days following the inspection.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

The equipment in use was maintained and serviced as per manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

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. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had infection control procedures that reflected published guidance. However, improvements were required to ensure these were reflective of the practice protocols.

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. However, improvements were required to ensure they were following the manufacturer’s instructions of the water treatment used in the Dental Unit Water Lines.

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