Horn Mews 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.

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 providers processes for identifying and managing some risks such as dental radiography, medical emergencies, Legionella and fire risk management required strengthening. Processes for sharps safety, sepsis awareness and lone working required improvement.

Staff demonstrated an open culture in relation to people’s safety.

Staff were not checking medical emergency equipment and medicines in line with national guidance. Systems for checking emergency drugs required strengthening, as missing and out of date items within the emergency kit had not been identified. Following the inspection the provider submitted evidence confirming that the required items had been ordered and that effective weekly checklists would be put in place.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. However, the provider did not have a satisfactory electrical installation condition report (EICR) certificate for the service. We were told some work had been undertaken as a result of the last report, but there was no evidence to confirm this. It was later provided and confirmed this was now satisfactory.

The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available.

Fire exits were clear and well signposted. However, procedures for managing fire safety required strengthening. There was one smoke alarm in the building and checks had been undertaken to ensure this was in working order. Fire drills had been undertaken, but there was no emergency lighting or alternate method to ensure safe evacuation, minimize panic and prevent injury during a power failure, fire or emergency. An internal fire risk assessment had been completed by the provider, however they had not identified or mitigated the risks found during our inspection.

Control of Substances Hazardous to Health (COSHH) risk assessments had been completed, but the provider did not have the required safety data sheets.

Staff told us conventional sharps were used during treatment. A sharps risk assessment was not in place, we noted sharps bins were not stored securely, there were no sharps injury posters available in treatment and decontamination rooms and there were no needle guards available in treatment rooms. Following the inspection we were provided with evidence that a sharps injury poster was in place in a decontamination room, however on the day of inspection when asked, staff were not aware. We were told dental rubber dam was not in use for complex procedures such as root canal treatments.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy and procedures to help them employ suitable staff. We found that although these reflected relevant legislation, they were not consistently applied and required pre-employment information was not always available for all staff.

There were no risk assessments in place for staff who had not completed their hepatitis B vaccinations and obtained confirmed immunity. There were no lone worker risk assessments for staff working alone in the practice.

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

There was scope to ensure newly appointed staff had an appropriate role specific structured induction which reviewed all areas within the practice including practice policies, infection prevention and control, medical emergencies, fire safety, safeguarding, radiography and decontamination processes.

Staff had the skills, knowledge and experience to carry out their roles. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. However, not all staff knew or were confident on how to escalate safeguarding concerns within the practice and externally.

The practice ensured staff training, including continuing professional development, was up-to-date, there was scope to ensure the practice reviewed these at the required intervals.

Staff described regular informal discussions with the provider and chats on social media groups for staff discussion. However, there were no structured or recorded practice team meetings, annual appraisals or one-to-one meetings where staff could discuss their learning needs, general wellbeing and aims for future professional development.

Staff told us they were proud to work in the practice.

There was scope to ensure all staff received appropriate training and could demonstrate knowledge and awareness of infection prevention and control processes.

Processes to ensure staff used personal protective equipment and decontamination of dental instruments after use, required strengthening. We noted zoning in treatment rooms between dirty and clean areas was not in place, there were no handwashing sinks in decontamination rooms and treatment room cleaning checklists were not completed. Systems to decontaminate dental instruments after use, were not in line with national guidance. There were no logs for the weekly changes of brushes or heavy-duty gloves. Checklists of equipment performance were not always completed and not signed.

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

The practice procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance required strengthening. An internal Legionella risk assessment had been undertaken in 2012 by the provider. However, there was no evidence to confirm if this had been reviewed or if any actions were identified or required.

There was scope to strengthen processes for the safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed an infection prevention and control audit; however, this was carried out annually rather than 6 monthly which was not in line with current guidance. We identified scope for improvement in ensuring data was analysed after it was gathered and action plans developed where required.

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