Norwich Street 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 the provider has made the required improvements.

During our inspection of this key question, we found concerns related to the safety of the premises especially regarding electrical and fire safety, emergency medicines and equipment, a lack of risk assessments for health and safety, lone working, sharps, control of substances hazardous to health (COSHH), and the absence of a process to receive alerts, recalls and safety information from the Medicines and Healthcare products Regulatory Agency (MHRA).

These concerns were in breach of Regulation 12.

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 did not identify or manage all risks effectively. There were no risk assessments for sharps safety or lone working. Additionally, we saw that there was no health and safety risk assessment.

The practice did not have an Electrical Installation Condition Report (EICR) to ensure the electrical system and wiring in the building was safe.

We saw that an external fire risk assessment had been completed just prior to this inspection. This highlighted multiple actions, some of which needed to be completed within one month. There was no action plan or timescale for completing these required actions. A previous fire risk assessment had been completed in 2022 which had also highlighted multiple actions which needed immediate completion. These had not been carried out. The practice was not carrying out fire evacuation drills, the smoke alarms which had been advised to be replaced were still present, there was no emergency lighting and no signage to direct service users and staff to the exit in the case of a fire. Not all staff had fire training.

Staff could access emergency equipment and medicines that were checked on a regular basis. These routine checks, however, were ineffective as they had not identified missing items of equipment and missing emergency medicines. We saw that there was no midazolam (a medicine used to treat prolonged seizures), no paediatric defibrillator pads, no spacer (used in the treatment of asthma) and not all sizes of oropharyngeal airways were present. Additionally, there were no blood or bodily fluids spillage kits, and no eye wash. Staff had completed training in emergency resuscitation and basic life support.

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

The practice did not have a designated Control of Substances Hazardous to Health (COSHH) folder. There were also no documented risk assessments or Safety Data Sheets available for any hazardous substance used within the practice.

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

The practice had some arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. However, the practice had not notified or registered with the Health and Safety Executive. 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.

We saw that the practice did not have a process in place for alerts, recalls and safety information on drugs and medical devices from the Medicines and Healthcare products Regulatory Agency (MHRA) to be received, evaluated and acted upon.

The practice did not have a recruitment policy. We saw that there was no evidence of immunity to Hepatitis B for one staff member, and no appraisal was being carried out. Additionally, there was no Disclosure and Barring Service (DBS) certificate or associated risk assessment for a staff member who had worked at the practice for many years.

Staff had most skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. There was no safeguarding policy and there was no information about how to report concerns in the practice. We saw that not all staff had up to date safeguarding training.

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

The practice had infection control procedures that generally reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

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

The practice had some procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. However, a risk assessment had not been completed. Following this feedback, we saw that the owner carried this out, but we did not see evidence that they had the training, knowledge or experience to demonstrate they were competent to carry out the risk assessment.

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.

We saw that the refrigerator was being used to store both clinical and non-clinical products.

The practice did not complete any infection prevention and control audits. These should be carried out every 6 months in line with current guidance.

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