Oakthorpe Dental

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 and equipment, availability of emergency equipment and medicines, safe and effective recruitment of staff, the support and development of staff and the infection prevention and control standards not being followed at the practice.

These concerns were in breach of Regulations 12, Safe care and treatment and Regulation 19, Fit and proper persons employed.

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 had ineffective processes to identify and manage risks effectively. The health and safety risk assessment was not sufficiently comprehensive and did not provide assurance that all actions identified had been completed. In addition, a sharps risk assessment had not been carried out. We also found that the fire risk assessment had been carried out by a person who could not demonstrate they had the skills, knowledge and competence to assess the risks associate with fire at the premises. Following the inspection, we received confirmation that a fire risk assessment by a suitably qualified external contractor had been arranged.

Staff demonstrated an open culture in relation to people’s safety. They felt confident that risks were well managed at the practice, and this was not wholly reflected in our findings.

The management of fire safety was ineffective. We did not see documentary evidence to demonstrate that routine checks of the emergency lighting and fire equipment, or that fire drills had taken place. An Electrical Installation Condition Report (EICR) was not available for review. Fire exits were clear and well signposted. Following the inspection, we received confirmation that an EICR had been arranged.

Staff had access to emergency equipment and medicines that were checked in line with national guidance. However, we noted the emergency equipment was stored behind a locked door and not easily accessible. During the inspection, we saw staff experience difficulty gaining access to the room where the equipment was stored. In addition, the temperature of the fridge that was used to store glucagon was not monitored to ensure it is being stored within the manufacturers recommended range. This meant there was no assurance that this would be effective if required in a medical emergency.

Staff 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, well maintained and free from clutter. However, carpet was present within a treatment room, which does not meet infection prevention and control standards as it cannot be effectively cleaned or decontaminated. Whilst the practice had attempted to separate the area using low cabinets, this arrangement is insufficient to mitigate the risk of aerosol contamination.

Hazardous substances were clearly labelled and stored safely. However, not all relevant products had been identified or have appropriate risk assessments accessible to staff, in line with Control of Substances Hazardous to Health (COSHH) Regulations 2002.

We saw satisfactory records of servicing and validation of all 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. However, the previously completed radiography inspection report had no evidence that the advised actions had been completed/reviewed.

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.

The practice had a recruitment policy and procedure to help them employ suitable staff, including agency or locum staff. These reflected the relevant legislation but were not always being followed.

Information relevant to staff employment in their role as required under Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was not consistently available. For example, evidence of Hepatitis B immunity (titre levels) was not available for 3 clinical staff members and there was no risk assessment in place; satisfactory evidence of conduct in previous employment was not available for 5 staff members; satisfactory information about any physical or mental health conditions and evidence of an appropriate role specific structured induction was not available for any staff.

There were ineffective 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 informal discussions, although these were not documented.

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

Staff had the skills, knowledge and experience to carry out their roles. Although, staff told us that there were not always enough staff on duty. 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.

The practice ensured staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

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

The practice had infection control procedures in place; however they did not wholly reflect published guidance and were not always being followed. For example, the practice was not adhering to the national colour-coding system for cleaning equipment. We saw the equipment was not appropriately segregated when stored, which increased the risk of cross-contamination. In addition, there was no evidence to demonstrate effective oversight of environmental cleaning schedules.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes, although gaps in knowledge were identified.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance.

The practice had ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment in line with current guidance was not available to evidence that the associated risks had been assessed, or that appropriate control measures and recommendations were in place. In addition, cold water temperatures were not being monitored or recorded to ensure they remained within an appropriate range. Following the inspection, we received confirmation that improvements were being made and a risk assessment was due to be carried out by an external contractor.

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste. However, the external clinical waste bin was accessible to the public and was not secured in a way that prevented unauthorised access or removal.

The practice completed infection prevention and control (IPC) audits, but these were not reflective of practice. For example, the audit did not identify that foot operated clinical waste bins were not available in clinical rooms.

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

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