Archived: Sydenham Dental Surgery

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 they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low.

During our assessment 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.

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

You can find more details of our concerns in the evidence category findings below. Whilst there are issues to be addressed, the impact of our concerns relate to the governance and the oversight of the risks, rather than a patient safety risk.

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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Staff we spoke with told us that equipment and instruments were well maintained and readily available.

The provider described the processes they had in place to identify and manage risks. There was scope for improvement regarding some of these processes as risk assessments seen required updating or were not accurate.

We were not assured that staff had completed training in fire safety and emergency evacuation of the premises. Staff we spoke with could not confirm they had undertaken any fire safety training and records of fire safety training were not available.

Not all emergency equipment and medicines were available and these were not checked in accordance with national guidance. Staff could access medical emergency equipment in a timely way. Following this assessment we received evidence to demonstrate that all necessary equipment and medicines had been purchased and were available for use.

The premises appeared visibly clean and free from clutter. Some maintenance issues were identified during this assessment. Hazardous substances were clearly labelled but not all were stored safely.

There was scope for improvement regarding the servicing and validation of the autoclave as this had not been serviced in line with manufacturer’s instructions. Records seen regarding validation of the equipment were not accurate.

Fire exits to the rear of the building were clear and well signposted, there were no fire exit signs at the front of the building. Fire extinguishers were serviced and well maintained. There was no other fire safety equipment on the premises. Following this assessment a certificate of Design, Installation and Commissioning of a Fire Alarm System was submitted.

There was scope for improvement in the processes to ensure that equipment was safe to use and maintained and serviced according to manufacturers’ instructions. Some improvements were needed to the floor within the decontamination room and patient/staff toilet as holes in the flooring were evident.

An internal fire safety risk assessment had been carried out which recorded inaccurate information. There was scope for improvement regarding the management of fire safety. Following this assessment we received a copy of a design, installation and commissioning certificate of a fire detection and alarm system which had been installed at the practice.

The practice had arrangements to ensure the safety of the X-ray equipment. The provider did not have evidence to demonstrate registration with the Health and Safety Executive for the use of X-rays.

The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health although these were not all fully completed. Safety data sheets for products in use were not available at the practice.

There was scope for improvement regarding the practice’s systems to assess, monitor and manage risks to patient and staff safety.

The practice’s systems for appropriate and safe handling of medicines required improvement. Glucagon was not being stored in the fridge and the expiry date had not been adjusted accordingly. Following this assessment we received evidence to demonstrate that a new Glucagon had been purchased and the expiry date amended accordingly. Antimicrobial prescribing audits were not carried out.

Staff had been working at the practice for over 10 years but told us that they did not receive regular update training. They told us that there were sufficient staffing levels.

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

Staff confirmed that they did not formally discuss their training needs and aims for future professional development.

Staff we spoke with demonstrated some knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff were not aware of ‘Was not bought’ where a child is not bought to their appointment by their parent and there was no guidance or other documentation available.

Staff told us they had worked at the practice for over 10 years but remembered receiving an orientation to the practice upon employment. There was no evidence of a structured induction programme for staff, which included safeguarding.

The practice’s recruitment policy and procedure required updating to ensure it reflected the relevant legislation. Systems to monitor and track the recruitment of staff were ineffective as there was no recruitment information on the premises.

There was no documentary evidence to demonstrate that staff had the skills, or knowledge to carry out their roles. The practice employed one trainee dental nurse who had been employed for a number of years but had not enrolled onto a training course. Following this assessment, the trainee nurse enrolled on a training course and evidence was sent to demonstrate this.

The practice did not have arrangements to ensure staff training was up-to-date and reviewed at the required intervals. There was no information on the premises to demonstrate any formal or other training completed by the trainee dental nurse or the receptionist.

We saw the practice did not have effective processes to support and develop staff with additional roles and responsibilities.

There was no effective schedule in place to ensure that the practice was kept clean or logs to demonstrate cleaning completed. We saw that drawers in the dental surgery were dirty and in need of cleaning. Local anaesthetic cartridges were not stored in blister packs in these drawers. Sharps boxes had not been appropriately labelled.

Hazardous waste was segregated and disposed of safely.

We did not observe the decontamination of used dental instruments as there were no patients at the practice on the day of assessment and the trainee dental nurse who would complete the decontamination process was not available.

There was scope for improvement regarding the practice’s infection control procedures. The decontamination equipment in use was overdue for servicing and maintenance records were inaccurate. We saw single use items were not reprocessed.

There was no evidence to demonstrate that the trainee dental nurse had completed appropriate training. Infection prevention and control (IPC) audits were not completed at the frequency suggested in current guidance.

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

The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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