Ashley Down Dental Care

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 assessment of this key question, we found concerns related to the safety of equipment, recruitment, training, support and development of staff, and the infection prevention and control standards being followed at the practice.

This resulted in a breach of Regulations 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 management of the availability of emergency equipment and medicines required improvement to ensure national guidance was followed.

Emergency medicines and equipment were checked monthly. Checks should be weekly in line with Resuscitation Council UK guidelines.

The premises were visibly clean and well maintained, and public areas were free from clutter.

Control of substances hazardous to health (COSHH) cleaning materials were stored in a stock room, however appropriate safety signage was not in place.

COSHH risk assessments and safety data sheets were not available for every COSHH applicable substance used at the practice, and they were not available for the cleaner.

We noted the presence of a clear liquid in a bottle marked ‘sterilising solution.’ The bottle label did not include COSHH information or an expiry date.

The clinical waste storage cupboard at the rear of the premises did not display a warning sign to alert people about the existence of the waste.

The practice had processes to identify and manage risks, but improvement was needed.

Dental radiography was not being carried out in line with relevant regulations and guidance. There was insufficient evidence to demonstrate compliance with key safety requirements or that identified actions from previous assessments had been completed.

Recording of prescription pads was not accurately maintained. There was evidence of one NHS prescription issued without records of the appropriate medical checks.

The fire risk assessment had been carried out internally by a person who could not demonstrate the competency to do so.

Fire safety management processes did not ensure that emergency lights were tested.

Emergency lights were not serviced or their batteries discharged.

Fire drills records were not available.

Damage to flooring in the decontamination room required attention.

A carbon monoxide detector was not available to protect patients and staff.

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

They told us that there were sufficient staffing levels.

Staff knew their responsibilities for safeguarding adults and children.

The practice ensured clinical staff were registered with the General Dental Council.

There were processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during ongoing informal discussions.

The practice had a recruitment policy which reflected the relevant legislation but was 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.

Several staff records were incomplete, with missing information relating to Disclosure and Barring Service (DBS) checks, employment history, reasons for leaving previous roles, induction, conduct in previous employment, and health assessments.

Evidence to confirm the effectiveness of Hepatitis B vaccinations was not available for all clinical staff, and safety measures such as risk assessments were not available.

Indemnity insurance records were not complete.

There were ineffective arrangements to ensure staff radiology training was up-to-date and reviewed at the required intervals.

Appropriate training records were not available for the nursing staff who took radiographs.

A lone worker risk assessment was not available for staff working alone.

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

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

Reprocessing of single use items was taking place for example burs (an instrument used to cut into teeth or bone) and single use child size saliva ejection adaptors, which is not in line with the manufacturer’s instructions and the Health Technical Memorandum 01-05 guidance.

Colour coded cleaning equipment was not separated when stored, which increased the risk of cross infection. Oversight of cleaning standards could not be evidenced.

Staff uniforms and outdoor clothes were stored in lockers. These were not separated to prevent the risk of cross contamination.

The frequency of infection prevention and control audits did not align with current infection control Health Technical Memorandum 01-05 guidance.

Out of date sterilising spray was used to spray lab work before being sent away. We were told that returned lab work was not sterilised before being placed in patients’ mouths.

A sharps bin was not labelled appropriately.

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

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 recommendations were not acted upon. Temperature checks identified that temperatures were not within the appropriate range to prevent the development of Legionella bacteria, but no action had been taken. The practice was not monitoring the temperature of water from both identified sentinel taps.

Evidence of appropriate training to effectively manage the risks associated with Legionella bacteria in water systems was not available for the person responsible for Legionella.

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