Clover 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 line with the relevant regulations and had taken into consideration appropriate guidance.

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 had 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 identified and managed some risks and staff described the processes in place to do this. This included sharps safety, sepsis awareness and lone working. However, environmental risks posed by the building in relation to fire safety had been identified but had not been addressed.

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 premises were visibly clean. Hazardous substances were clearly labelled and stored safely.

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

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

The provider had commissioned two fire safety risk assessments on the practice building over a two-year period. Both reports drew attention to matters that posed risk in terms of fire safety, and in the configuration of additional rooms that had been opened for use on the lower floor of the building. The reports drew attention to the non-conformity with building regulations posed by these rooms and the impact on fire safety, and compromised escape routes for people in these rooms.

The practice had systems for appropriate and safe management of medicines. When we looked at how stock could be checked and accounted for, we found two systems in place across paper-based records and computer held records. This system was not effective as it would not enable the practice manager to immediately balance stock dispensed by clinicians, alongside stock held, stock drawn down from stores and new stock received.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff.

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

Newly appointed staff had an appropriate role specific structured induction.

Staff had the skills, knowledge and experience to carry out their roles. They 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.

Overall we found the practice ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals for the majority of staff.

There were processes to support and develop staff with additional roles and responsibilities, but this system was not effective. On our inspection day, we observed that there was an onsite laboratory, where custom oral health and dental devices were being made. The practice was unable to demonstrate that they were appropriately registered with the Medicines and Healthcare Products Regulatory Agency (MHRA) for all the custom-made devices they were producing. There was also confusion regarding registration of the laboratory at its location address.

Staff discussed their learning needs, general wellbeing and aims for future professional development during appraisals, practice team meetings and ongoing informal discussions.

Staff felt respected and valued, and they were happy in their work in the practice.

The practice had infection control procedures in place, but these did not always reflect published guidance or manufacturer guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes. However, for certain processes, there was a lack of documentary evidence and logs, with some staff assuming these were held in computer records, and other staff assuming it was held in paper logs. For example, staff told us that foil ablation testing on the ultrasonic bath was carried out but couldn’t show any evidence of this. We were told that protein residue testing was carried out periodically, but there was no record of this.

Staff used personal protective equipment and decontaminated dental instruments after use with the use of autoclaves, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had procedures in place to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. We saw that staff were measuring and recording hot water temperatures, which should be above 50 degrees centigrade. When records showed temperatures recorded below 50 degrees centigrade, this was not escalated. This indicated a lack of understanding of effective management of Legionella using thermic control.

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. We questioned the effectiveness of these audits as they did not reflect the points highlighted by this inspection.

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