John Sullivan Dental Practice Limited

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 providing safe care in accordance with the relevant regulations and had taken into consideration appropriate guidance.

Althoughthere are issues to be addressed, the impact of our concerns relatesto the governance and the oversight of the risks, rather than apatientsafety 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.

The practice had systems to identified and manage risks and staff described the processes. This included sepsis awareness and lone working. Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice. However, this was not always reflected in our findings.

The practice had carried out a health and safety risk assessment to help them manage risks to staff and patients. However, this was last completed in March 2016 and had not been reviewed since. We also noted that the sharps injury poster was not up to date and staff were unclear of how they would seek urgent medical advice in the event of a sharp’s injury. The provider has confirmed the health and safety risk assessment and policy had been reviewed and updated, and a new sharps injury poster implemented shortly after the inspection.

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

Staff could access most emergency equipment and medicines. However, these were not checked in line with national guidance and as a result, some equipment was missing. We also noted that storage of emergency medicines should be improved in relation to expiry dates. The practice should review the necessity of a second oxygen cylinder where appropriate in line with the guidelines issued by the Resuscitation Council (UK).

The premises were visibly clean, well maintained and free from clutter. Documentation to evidence environmental cleaning was not available on the day of inspection. The provider submitted a new cleaning schedule and cleaning log following the inspection.

Hazardous substances were clearly labelled and stored safely. However, risks associated with the Control of Substances Hazardous to Health (COSHH) were not always appropriately managed. For example, not all hazardous substances used at the practice had COSHH risk assessments. The COSHH risk assessments for 5 of the substances we saw on the day of inspection were last reviewed in January 2012.

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

The practice managed fire safety well, and fire exits were clear and well signposted. Staff were testing fire equipment and had participated in regular fire drills and fire training. However, an up-to-date fire risk assessment had not been completed in line with legislation. We also noted documentation of fire drills did not always record everything required. The provider took immediate action and booked a fire risk assessment. We also discussed documentation of fire drills with the practice manager and were assured this would be addressed.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

We were unable to view or access staff recruitment files on the day of inspection due to an IT issue at the practice. We were therefore unable to assess the recruitment processes. The provider confirmed and assured us that all staff recruitment files and training for all members of staff was available following the inspection. Recruitment processes will be assessed at our follow-up inspection.

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

The practice manager told us that newly appointed staff had an appropriate role specific structured induction, including locum staff.

The provider told us they ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Staff we spoke with on the day of the inspection demonstrated knowledge and understanding of the key aspects of providing dental services. We were not able to review training certificates on the day of inspection due to the provider’s IT issues. These will be reviewed at our follow-up inspection.

Staffdemonstrated someknowledge of safeguarding; they told us they would report any concerns they had to the principal dentist or the practice manager. However, staff had limited knowledge of the terminology Was Not Brought (WNB) and how this should be implemented at the practice and there was limited supporting documentation for staff in the form of policies and process charts. Information that was available to support staff was out-of-date. Was Not Bought replaced the previous terminology Did Not Attend, to encourage and emphasise the importance of considering the reasons behind missed appointments and the safeguarding implications of this. The provider took immediate action and created a safeguarding policy and flowchart and implemented a new Was Not Bought process.

Staff told us they discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, one-to-one meetings, during clinical supervision and practice team meetings and ongoing informal discussions.

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

The practice had infection control and decontamination procedures that reflected published guidance. However, these were not consistently followed in relation to manual decontamination of dental instruments.

Staff were using heavy duty gloves when manual cleaning, but there was no oversight of how often these were being changed. In addition, staff were not always using adequate personal protective equipment or checking the temperature of water when undertaking manual cleaning, and the staff could not access the data logger for an autoclave. The provider took immediate action to address these issues.

Staff demonstrated knowledge and awareness of infection prevention and control processes.

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

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.

Staff described protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

Most equipment was maintained and serviced in line with manufacturers’ instructions. It was not possible to review a gas safety certificate, electrical installation condition report and portable appliance testing (PAT) on the day of inspection due to the provider’s IT issues. We will review these during the follow-up inspection.

The practice completed infection prevention and control audits in line with current guidance and at the required frequency. However, the audits did not identify the shortfalls we identified on the inspection day.

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