Holloway House Dental Surgery

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 not providing safe care in line with the relevant regulations and had not taken into consideration appropriate guidance.

We will be following up on our concerns to ensure the provider has made the required improvements.

During our inspection of this key question, we found concerns related to the safety of the premises, equipment, the adequacy and availability of emergency equipment and medicines, and the infection prevention and control standards being followed at the practice.

These concerns were in breach of regulation 12, Safe Care and Treatment.

You can find more details of our concerns in the detailed findings below.

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 processes to identify and manage risks, but immediate improvement was needed.

Staff knew how to respond to a medical emergency and all staff had completed training in emergency resuscitation and basic life support every year.

Checks of emergency equipment and medicines did not follow national guidance to ensure availability and suitability for use.

The practice had not carried out risk assessments in relation to the safe storage and handling of every substance hazardous to health that was in use by staff.

The practice did not ensure equipment was safe to use and maintained and serviced according to manufacturers’ instructions.
Areas both inside and to the rear of the practice contained a quantity of discarded clinical equipment and materials.

X-ray local rules did not include all of the information required to comply with the Ionising Radiations Regulations 2017.

Not all of the X-ray equipment had the corresponding evidence available to demonstrate machines were used safely and maintained and serviced as per manufacturers’ instructions.

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.

The provider did not have effective fire safety management procedures.

NHS prescriptions were not monitored to prevent fraudulent misuse.

The practice had not implemented systems to assess, monitor and manage risks to patient and staff safety. In particular, the management of sharps.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff.

Recruitment records were not stored appropriately. Which meant that we were unable to review information to assure ourselves that recruitment checks for permanent staff had been undertaken appropriately. We have since received evidence to confirm this shortfall has been addressed.

Recruitment and training records were not available for specialist clinical staff who occasionally visited the practice.

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 training, including continuing professional development, was up to date however, not all relevant staff could demonstrate knowledge and awareness of safeguarding reporting processes.

Staff discussed their learning needs, general well-being and aims for future professional development during informal discussions.

Records of Hepatitis B antibody levels were not obtained for all clinical staff. This was contrary to the practice's sharps risk assessment. Improvements could be made to take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

All of the staff we asked told us they felt respected, supported and valued, and they were proud to work in the practice.

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

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

Improvement was needed to ensure that infection control procedures reflected published guidance.

Evidence to confirm staff had oversight of cleaning standards was not available.

Not all relevant staff could demonstrate knowledge and awareness of infection prevention and control processes.

Records to confirm that routine ultrasonic bath validation checks had been carried out were not available.

The storage and decontamination of instruments was not carried out in accordance with The Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM 01-05) guidance.

The practice infection prevention and control audits results did not reflect current practice.

Practice environmental cleaning protocols did not meet national standards.

The practice could not demonstrate that effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance were in place. The resulting actions required from a recent risk assessment remained outstanding at the time of our visit.

Not all clinical staff adhered to personal protective clothing and footwear protocols in line with national infection prevention and control guidance.

An annual infection prevention and control statement was not available.

Hot water was not available in staff and patient toilet and staff kitchen.

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