Queens Square Dental

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 they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low.

During our assessment of this key question, we found concerns related to fire safety, management of medical emergencies, recruitment and training of staff, sharps safety and infection prevention and control standards being followed at the practice. This resulted in a breach of Regulation 12 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 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 processes to identify and manage risks, but immediate improvement was needed. For example, systems and processes to ensure the effective management of sharps safety and sepsis awareness did not reflect practice protocols.

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

Staff could access most emergency equipment and medicines that were checked in line with national guidance. However, the checks had not identified missing items.

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 all equipment was safe to use and maintained and serviced according to manufacturers’ instructions. There was no evidence of servicing for the compressor, or gas boiler and the 5-yearly electrical installation condition report was overdue.

Not all of the X-ray equipment had the corresponding evidence available to demonstrate machines were used safely. 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.

The practice did not have an adequate stock control system of prescriptions and dispensed medicines.

The practice had a recruitment policy and procedures that reflected relevant legislation. However, these were not consistently followed and oversight of recruitment checks required improvement. On the day of inspection, multiple documents related to recruitment checks were missing or not available in staff files. The provider submitted these after the inspection visit.

The practice ensured clinical staff were qualified and registered with the General Dental Council (GDC) and had evidence of appropriate professional indemnity cover.

The practice did not carry out a structured induction for every newly appointed member of staff.

The practice should take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

Staff we spoke with generally 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.

Trainee dental nurses did not know who their formally appointed GDC registered supervisor was.

Staff demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. They knew how to escalate safeguarding concerns within the practice and externally.
 

Training was not monitored to ensure staff were up-to-date with their mandatory training and their continuing professional development (CPD).

The practice’s infection control procedures did not reflect current published guidance.

Not all relevant staff received appropriate training or demonstrated knowledge and awareness of infection prevention and control processes.

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

The 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 did not have adequate procedures to reduce the risk of Legionella or other bacteria developing in water systems.

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

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

The practice had not carried out infection prevention and control audits six-monthly following current guidance and legislation.

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