Hatherley 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.

During our inspection of this key question, we found concerns related to the safety of the premises regarding fire safety, adequacy and availability of emergency equipment, radiography, staffing and Legionella. There was also a lack of systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

This resulted in a breach of Regulation 12, Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

Processes to identify and manage risks required strengthening. Staff felt confident that risks were well managed at the practice however, this was not reflected in our findings.

Systems for checking emergency equipment and medicines required strengthening as they had not identified that items of medical emergency kit were missing or out-of-date. Items that were missing or were found to be out-of-date were ordered following our inspection. Weekly checklists were introduced following our inspection to ensure all items were present and expiry dates had not been exceeded.

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

The practice had not carried out risk assessments to minimise the risks that could be caused from substances that are hazardous to health. Safety data sheets were available.

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

The practice had minimal arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was not available. This included handheld X-ray equipment. The equipment in the treatment room had not been serviced since 2017. Evidence was not available to confirm the handheld X-ray unit had ever been serviced. The provider did not have evidence to demonstrate registration with the Health and Safety Executive for the use of X-rays. This was carried out following our inspection. There was no evidence of registration of a Radiography Protection Advisor (RPA), and the local rules were out-of-date. Radiography audits were not carried out. 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 management of fire safety was ineffective. A safety risk assessment had been carried out by the provider in 2014 however, there was no evidence to demonstrate this had been reviewed. At the time of our inspection there was no documented monitoring of fire safety equipment. Fire extinguisher servicing was out-of-date and emergency lighting had not been serviced. Fire drills were not carried out.

Fire exits were clear and well signposted.

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

Antimicrobial prescribing audits were not carried out in line with guidance.

The practice had a recruitment policy and procedures that reflected relevant legislation, to help them employ suitable staff. There were some systems in place to ensure clinical staff had received appropriate vaccinations, including vaccination to protect them against the Hepatitis B virus. However, we found the effectiveness of the vaccination was not known for all clinical staff and 1 member of staff had not completed the vaccination program. Following our inspection, appointments were made for those staff members to gain assurance around vaccination status.

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 structured induction.

They told us that there were enough staff on duty at all times. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice did not ensure that staff completed safeguarding training to the appropriate level or updated their training at appropriate intervals. Some evidence of training for staff was submitted following our inspection.

The practice did not have arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. We were assured by the practice that this would be monitored in the future.

There were processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during ongoing informal discussions.

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

The practice had some infection control procedures that required strengthening to reflect published guidance. We identified several out-of-date dental materials and out-of-date pouched dental instruments. These were removed immediately during our inspection.

We observed use of personal protective equipment. We saw and staff confirmed that single -use items were not reprocessed.

Procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment, required improvements. We found the hot and cold-water temperatures were not monitored consistently and there were actions to be addressed from the risk assessment.

Although most patient areas of the practice appeared clean, there was no effective schedule in place to ensure that the practice was kept clean or logs to demonstrate cleaning completed. We observed safe segregation and disposal of hazardous waste.

Some improvements were required to the flooring in the treatment room.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance however, we found these were not reflective of our observations of processes in place at the service.

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