Aberdeen House 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.

Although 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.

During our inspection of this key question, we found concerns related to:

The safety of the premises, adequacy and availability of emergency equipment and medicines, recruitment and training, support and development of staff, and the infection prevention and control standards being followed at the practice.

These concerns were in breach of Regulations 12 and 17.

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 had ineffective processes to identify and manage risks. A sharps risk assessment had not been carried out, a health and safety risk assessment was not sufficiently comprehensive, and a fire risk assessment had been carried out by a person who could not demonstrate they had the skills, knowledge and competence to assess the risks associate with fire at the premises. Following the inspection, we received evidence that a fire risk assessment by a suitably qualified external contractor had been arranged.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, but this was not wholly reflected in our findings.

The management of fire safety was ineffective. We did not see documentary evidence of the routine checks of the emergency lighting, fire equipment or fire alarm and an Electrical Installation Condition Report (EICR) was not available for review. Fire exits were clear and well signposted. However, we saw fire doors were propped open with wedges, preventing closure in the event of a fire. Following the inspection, we received evidence that an EICR had been carried out in 2023, and although unsatisfactory at that time, we have seen evidence that remedial works have been completed. We also received evidence that a fire risk assessment has now been carried out. However, this identified several areas requiring improvement. The provider has confirmed their plans to address and complete the required actions.

Staff could access emergency equipment and medicines, but these were not being effectively checked in line with national guidance. The checklist did not include all of the necessary information and did not identify issues with the available medicines and equipment. Several items were out of date, missing or not appropriate for use, including the pads for the Automated External Defibrillator (AED), airways, oxygen face masks, dispersible Aspirin, and the needles and syringes to administer adrenaline and this had not been identified by checks, and no action had been taken. In addition, the Glucagon medication was inappropriately stored in a fridge containing food and the temperature was not being monitored. Immediate action was taken to replace the items and following the inspection we received confirmation that the appropriate equipment was available, and a second fridge had been installed to ensure separation of clinical and non-clinical items.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. However, the annual update for this year was overdue.

The premises on the whole, were visibly clean, well maintained and free from clutter. However, the flooring, floor to wall seals and cabinetry in one surgery were not intact which could compromise effective cleaning. In addition, fabric furniture was present within clinical areas, which was not in line with infection prevention and control guidance. Following the inspection, we received evidence that the fabric furniture had been removed and improvements are ongoing to address the issues in the surgery.

Hazardous substances were clearly labelled and stored safely. However, the risk assessments and data sheets for control of substances hazardous to health (COSHH) had not been reviewed and updated regularly, and not all products had been identified.

The practice did not have wholly effective arrangements to ensure the safety of the X-ray equipment. Evidence of electromechanical servicing was not available for either of the X-ray units. Following the inspection, we received evidence that servicing of the X-ray units had been arranged. 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 systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and improvements were underway to upgrade the log in place to monitor and track their use.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. These reflected the 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, evidence of Hepatitis B immunity (titre levels) was not available for 1 staff member and there was no risk assessment in place; a full employment history and satisfactory evidence of conduct in previous employment was not available for 1 staff member; satisfactory information about any physical or mental health conditions and evidence of an appropriate role specific structured induction was not available for any staff.

Staff had the skills and experience to carry out their roles. However, we identified some gaps in their knowledge.

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 (GDC). For example, we saw gaps in the following mandatory and recommended topics: safeguarding adults and children, medical emergencies, Learning Disability and Autism, Legionella, Mental Capacity Act, sepsis, and complaints handling.

There were ineffective processes to support and develop staff with additional roles and responsibilities. Staff told us they discussed their general wellbeing during annual appraisals, ongoing informal discussions and practice meetings, but their learning needs, and aims for future professional development were not documented.

Staff told us that 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.

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

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

The practice had infection control procedures that reflected published guidance but were not always being followed. For example, we noted that although the practice appeared clean, there were no cleaning schedules available for review, and no clear arrangements for maintaining cleanliness of the practice. In addition, the cleaning equipment was not stored appropriately. We saw over-flows on the sinks in 1 of the surgeries and in the decontamination room; 1 surgery did not have running hot water; distilled water was stored in unlabelled bottles, and it was unclear if the contents were being discarded within recommended timeframes; daily checklists were not available for review.

Staff were aware of infection prevention and control processes and had received appropriate training, but gaps were identified in their knowledge.

We observed the use of personal protective equipment and the decontamination of used dental instruments, which did not wholly align with national guidance. For example, a pre-enzymatic solution was in use, but it’s temperature checks were not recorded; we did not see records to demonstrate that weekly and daily testing on the equipment were being completed in line with manufacturer’s instructions or current guidance; instruments including X-ray holders, hand scalers and burs, kept in clinical areas, were not always pouched and some were pouched but undated.

The practice had ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment in line with current guidance was not available to evidence that the associated risks had been assessed, or that appropriate control measures and recommendations were in place. In addition, hot and cold water temperatures were not being monitored or recorded to ensure they remained within an appropriate range. Following the inspection, we received assurance that improvements were being made to the practice’s processes in line with a risk assessment carried out by an external contractor since the inspection.

The practice completed infection prevention and control (IPC) audits, but these were not reflective of practice or in line with current guidance. For example, audits were not completed at recommended intervals and did not include action plans.

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

Equipment was serviced in line with manufacturers’ instructions.

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