Cathedral 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 not providing safe care in accordance with the relevant regulations. 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, recruitment and training, support and development of staff. This resulted in a breach of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the evidence category findings below. Whilst there are issues to be addressed, the impact of our concerns relate 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 ineffective processes to identify and manage risks. Risk assessments for the use of sharps and lone working were not available, and the fire risk assessment detailed recommendations that had not been actioned. A policy for sharps was dated April 2011 and it was unclear when this had been reviewed. Additionally, sharps injury posters did not include details on who to contact in case of a sharps injury.

The management of fire safety was ineffective. Records of periodic testing or checks of the smoke alarms, emergency lighting or fire extinguishers were not available. In addition, a clearly documented record of fire evacuation drills was not seen. Fire exits were clear but not well signposted.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely, but not all dental materials and cleaning products had up to date risk assessments or safety data sheets accessible to staff, in line with Control of Substances Hazardous to Health (COSHH) regulations 2002.

The practice had some systems for appropriate and safe management of medicines, but anti-microbial prescribing guidance was not always being followed. For example, there was no dispensing or practice information on the labels of antibiotics. The log in place to monitor and track their use did not contain sufficient information, such as expiry dates of the medication.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

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

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. 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 practice had a recruitment policy and procedures to help them employ suitable staff, including agency or locum staff. These reflected relevant legislation but were not always being followed. Information relevant to staff employment in their role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was not always available. For example, Disclosure and Barring Service (DBS) checks were not seen for 2 staff and one staff had a basic DBS check which was not suitable for their role. Satisfactory evidence of conduct in previous employment was not seen for 2 applicable staff. Evidence of Hepatitis B immunity (titre levels) was not available for 3 staff members, and 2 further staff who were non-responders to the vaccine, did not have a risk assessment in place. Satisfactory information about any physical or mental health conditions was also not available for any staff and newly appointed staff did not have an appropriate role specific structured induction

The practice did not have arrangements to ensure staff training, including continuing professional development (CPD), was up-to-date and reviewed at the required intervals. Not all clinical staff were able to demonstrate that they had undertaken all CPD relevant to their roles as recommended by the General Dental Council. We saw gaps in the following topics: radiography, safeguarding adults and children, fire safety awareness, Mental Capacity Act, Legionella, infection, prevention and control (IPC), legal and ethical, oral cancer, learning disabilities and autism, Sepsis, and complaints handling.

There were ineffective processes to support and develop staff with additional roles and responsibilities. Although informal discussions took place, there was no documentary evidence of one to ones or appraisals to support staff members’ learning needs, general wellbeing or aims for future professional development. Following the inspection the practice told us they had implemented a performance review form to carry out appraisals.

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

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

The practice had infection control procedures that reflected published guidance, but these were not always being followed.

We observed use of personal protective equipment and the decontamination of used dental instruments. The decontamination room was cluttered, did not have a separate handwashing sink and both dirty and clean instruments were transported on open trays, not in lidded containers as per national guidance. We saw, and staff confirmed that single use items were not reprocessed.

Staff had not received appropriate training in infection prevention and control processes. The practice had ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment had been completed, but the recommended control measures were not acted upon when temperature checks identified that temperatures were not within the appropriate range to prevent the development of Legionella bacteria. Following the inspection, we received assurance that appropriate action had been taken.

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

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

The practice had completed infection prevention and control (IPC) audits, but these were not reflective of the practice or completed in line with current guidance.

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