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Yeovil 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 2 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6
Must do
Safe
Ensure the cleaning contractor conforms to published National Patient Safety Association (NPSA) guidance regarding cleaning of dental premises.
Must-do action 2 of 6
Must do
Safe
Implement recommendations in the legionella risk assessment carried for the Trust in 2013.
⚠ The access centre did not have a process in place to monitor water temperature from the standard domestic hot and cold facilities in the centre to ensure the safety of the general water systems. This had been highlighted in a risk assessment in 2013 but was still not being done …
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 personnel files some key information was missing. For example immunisation status was not always recorded, or if immunisation status had been 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 when carrying out domiciliary visits they take appropriate emergency equipment as advised by the British Society for Disability and Oral Health (BSDH) August 2009.
⚠ Emergency equipment used for domiciliary visits required review to ensure it was meeting appropriate national guidelines to ensure risks to these patients were reduced to be kept safe if an emergency arose. The domiciliary kit did not include a full emergency medicines kit, oxygen and an automated external defibrillator.
Must-do action 5 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 personnel files some key information was missing. Not all references received had been signed and gaps in employment had not always been explored and recorded.
Must-do action 6 of 6
Must do
Safe
Ensure all equipment is regularly serviced in line with approved guidance.
⚠ There were no records available during the inspection to evidence testing of the equipment or of the deep clean of the premises for the safety of patients. The centre could not provide documentary evidence to demonstrate the X-ray equipment in use had been serviced at recommended intervals. The Ionising Radiation …

Should-do actions (2)

Recommended improvements to enhance service quality.

Should-do action 1 of 2
Should do
Well-led
Should ensure the centre manager and senior clinician is empowered to make local decisions in the best interest of Yeovil DAC.
Should-do action 2 of 2
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).

Location details

CQC ID: RH5X6
Local authority: Somerset
Region: South West

Inspection report

Type: Location
Date: 17 March 2016
Actions: 6 must-do 2 should-do
AI-extracted 3 Jun 2026

Related PFD reports

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2025-0200 — Jacqueline Potter (Apr 2025)
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2018-0126 — Robin Richards (May 2018)