Source · CQC inspection

Bridgwater Dental Access Centre

Provider Somerset NHS Foundation Trust Type NHS Healthcare Organisation Region South West

Overall rating: Not Yet Rated  View full CQC report

Domain ratings

Five CQC key questions
Safe
Not Yet Rated
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Not Yet Rated

Earlier inspection findings

pre-2024 framework · 6 must-do 5 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6
Must do
Safe
Have in place records of what is expected of cleaners and records of schedules completed by the cleaners.
⚠ The senior dental nurse was unable to supply a cleaning plan, schedule and checklists for the newly employed contract cleaner.
Must-do action 2 of 6
Must do
Safe
Complete recommended actions following the legionella risk assessment to reduce risk to patients and staff using the access centre.
⚠ Recommended actions following a legionella risk assessment completed in May 2014 were not completed, such as monthly checks of hot and cold water temperatures.
Must-do action 3 of 6
Must do
Safe
Ensure immunisation status is recorded for all staff who have received hepatitis B immunisation as directed by the Code of Practice on the prevention and control of infections, appendix D criterion 9(f).
Regulation: Code of Practice on the prevention and control of infections, appendix D criterion 9(f)
⚠ In four staff files, immunisation status was not always recorded, or if recorded as needing attention, there was no clear process to identify who was responsible for ensuring appropriate action was taken and completed.
Must-do action 4 of 6
Must do
Safe
Ensure they take all the required emergency kit with them when undertaking domiciliary visits.
⚠ The domiciliary kit did not include a full emergency medicines kit, oxygen and an automated external defibrillator as routine, which did not reflect British Society for Disability and Oral Health guidelines.
Must-do action 5 of 6
Must do
Responsive
Ensure patients are not kept waiting longer than the standard wait time for referrals.
⚠ The centre had a waiting list of 124 patients who had passed the 18-week standard wait time for referrals.
Must-do action 6 of 6
Must do
Safe
Ensure staff were recruited safely according to the Trusts recruitment policy and Schedule 3 of the Health and Social Care Act 2008. Particularly ensuring references and gaps in employment were evidenced during the recruitment process.
Regulation: Schedule 3 of the Health and Social Care Act 2008
⚠ In four staff files, some key information was missing, including immunisation status, unsigned references, and unexplored/unrecorded gaps in employment.

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Well-led
The whistleblowing policy did not include information about who staff could raise concerns with externally such as the Care Quality Commission (CQC).
Should-do action 2 of 5
Should do
Safe
Have in place all oropharyngeal airways including size 0.
Should-do action 3 of 5
Should do
Well-led
Review the effectiveness of the system to ensure accurate records of annual servicing of compressors for all sites are maintained and available to the centre manager.
Should-do action 4 of 5
Should do
Well-led
Individualise patient feedback to enable a clear view of patient satisfaction at individual access centres.
Should-do action 5 of 5
Should do
Effective
Review whether training in learning disabilities is relevant and necessary due to high number of patients with a learning disability attending the practice.

Location details

CQC ID: RH5L3
Local authority: Somerset
Region: South West

Inspection report

Type: Location
Date: 17 March 2016
Actions: 6 must-do 5 should-do
AI-extracted 2 Jun 2026