Kendal Dental and Implant Centre

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.

This resulted in a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Premises and equipment.

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

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 leaders were unable to demonstrate that processes in place effectively identified and managed risks. Processes and procedures that were in place were not consistently followed and applied.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. The practice did not have records to confirm visiting dental professionals had completed medical emergency training.

The premises were visibly clean, and free from clutter. Hazardous substances were clearly labelled and stored safely. We found that Control of Substances Hazardous to Health (COSHH) data sheets were stored in a locked office, which the cleaner could not access.

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

The practice told us they had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available, for example, in relation to the servicing and testing of intra-oral X-ray equipment and local rules for users of the equipment. We observed local rules for X-ray equipment were generic and did not reflect the room each X-ray set was situated in.

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 electrical fixed wiring safety report for the practice had been done on 6 July 2023 and showed a number of concerns, with some of these being described as ‘urgent attention needed’. The overall rating of the fixed wiring was “Unsatisfactory”. A new safety report was commissioned and completed very recently. This showed the same 7 listed concerns and that the electrical fixed wiring in the building was again assessed as being “Unsatisfactory.” There was no communication within governance teams, or with staff working in the practice, on when these matters would be addressed.

The practice managed fire safety by ensuring fire exits were clear and signposted.

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 that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. These procedures were not consistently followed.

The provider was unable to give assurance that clinicians had sufficient professional indemnity in place to perform specialist procedures, for example dental implant treatment, or that their assisting staff were covered by their indemnity. Processes for checks on training and continuing professional development were not followed consistently. The provider was unable to show that dental professionals visiting the practice had up to date training in emergency medical procedures and use of emergency medicines.

Newly appointed staff to the practice, had an appropriate role specific structured induction.

The processes to support and develop staff with additional roles and responsibilities, did not work effectively. Our findings demonstrated the person assigned as the Radiation Protection Supervisor (RPS) had not had sufficient appropriate training to carry out this role. Local rules for the X-ray and CBCT equipment did not reflect or consider the location, layout and detail of where each piece of equipment was placed.

Staff told us there were enough 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.

For permanent staff, the practice ensured highly recommended training was up-to-date and reviewed at the required intervals. The systems in place to ensure medical emergency training had been completed by visiting clinicians and staff were not effective.

The practice had infection control procedures that reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. We found that recognised guidance was not consistently followed.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. On arrival at the practice, we saw that the entrance door to the decontamination room was wedged open, meaning decontamination processes were not contained. There was insufficient ventilation in this area.

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

Inspection findings showed staff did not consistently follow the Sharps Policy, which required dentists to use safer sharps or dismantle traditional sharps themselves. From checks on accidents and incidents nurses sustained injuries while handling sharps, including one incident after surgery hours when the dentist had left. The practice had not implemented basic measures to support the policy, such as having only having sharps bins in surgeries.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

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

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

The practice completed infection prevention and control audits in line with current guidance. However, these were ineffective as they had failed to bring the matters found in this inspection, to the attention of the provider.

The practice employed cleaning staff to clean the practice after hours. We asked to see data sheets for products used by the cleaners, in accordance with Control of Substances Hazardous to Health (COSHH) requirements. We reminded the provider that the cleaner should be able to access this information when on duty.

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