Mr Osman Mohammed Also known as Manningham Lane 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 providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

Although there are issues to be addressed, the impact of our concerns relates 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.

The provider had systems to assess health and safety of the premises, and had made improvements to refurbish the treatment room, reception area and taken action to secure doors to areas that should not be accessed by patients.

The premises were visibly clean, well maintained and free from clutter. We saw satisfactory records of servicing of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment and most radiation protection information was available. We highlighted the employers’ procedures and risk assessment documents should be completed and available in their radiation protection file.

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 practice managed fire safety well. Staff carried out checks on fire safety equipment and fire exits were clear and well signposted. We highlighted the provider should seek assurance about the servicing of the fire alarm and emergency lighting from the landlord and improve the fire drill evacuation time.

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 identified and managed sepsis awareness and lone working risks and staff described the processes. The systems to identify and manage risks from hazardous substances was not effective. Risk assessments were generic and not up-to-date with the products in use. In addition, we observed the storage of local anaesthetic in incorrectly labelled containers.

Staff could access emergency equipment and medicines that were checked in line with national guidance. We highlighted the kit could be better organised to enable staff to find items quickly.

We were not assured all staff knew the process to respond to a medical emergency and evidence had not been obtained of appropriate up-to-date emergency resuscitation and basic life support training for 2 members of staff. We highlighted staff should also participate in medical emergency scenario and induction training to ensure understanding of the process.

A sharps risk assessment was in place, and staff told us they followed safe handling procedures. However, we highlighted the contact details of the service to obtain advice and follow-up in the event of a sharps injury was incorrect. Staff took immediate action to obtain and display the correct details.

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

The practice had a recruitment policy that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, these were not followed. In particular, Disclosure and Barring Service (DBS) checks, work history and evidence of immunity against Hepatitis B were not consistently obtained or risk assessed.

No information was obtained for a temporary dental nurse who recently worked at the practice.

There was no appropriate role specific structured induction for any staff member.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding. Most staff were aware of how the practice’s safeguarding information could be accessed and how to escalate safeguarding concerns within the practice and externally.

However, the practice did not ensure that all staff completed safeguarding training to the appropriate level and discussions with recently appointed staff highlighted they had not been familiarised with the practice’s safeguarding processes, or how to find these.

Staff were provided with access to an online training portal, and during the inspection they showed us evidence they regularly undertook training appropriate to their roles. However, the practice did not have systems to consistently oversee and obtain evidence that all staff training were up-to-date and reviewed at the required intervals.

Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions.

The practice had an infection control policy that reflected published guidance. However, there were a lack of clear practice procedures, or communication between day and evening staff which resulted in inconsistent processes being followed. Staff we spoke to on the day gave assurance this would be addressed and effective communications put in place.

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

The practice had protocols to ensure effective cleaning and safe segregation and disposal of hazardous waste.

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. Instruments were clean and pouched appropriately after sterilisation, but staff used different dating methods to identify when these should be reprocessed. We highlighted that heavy duty gloves should be changed weekly, or before if visibly damaged.

The procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, were inconsistent. The dental unit waterline disinfectant used to prevent biofilm formation and maintain water quality was not used continuously in line with manufacturer’s instructions due to the lack of clear procedures and communication. We highlighted monthly cold-water temperatures should be taken from sentinel outlets identified in the risk assessment report.

Equipment was maintained and serviced in line with manufacturers’ instructions. We talked to staff who carried out validation checks on decontamination devices. The results of efficacy tests on the ultrasonic cleaner indicated this device was not performing as expected, but this had not been acted on.

The infection prevention and control audits were carried out in line with current guidance. However, these did not identify areas of improvement highlighted by the inspection

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