The Mall 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 and equipment, recruitment, and training, support and development of staff, and the infection prevention and control standards being followed at the practice.

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

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. A sharps risk assessment had been carried out but was not suitably comprehensive, and we did not see a health and safety risk assessment or a lone worker risk assessment. In addition, a 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 and was not reflective of practice. Following the inspection, we received evidence that the sharps risk assessment had been reviewed, and health and safety and lone worker risk assessments were now in place. A fire risk assessment by a suitably qualified external contractor had also been arranged.

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

The management of fire safety was ineffective. We did not see documentary evidence of the routine checks of the emergency lighting or fire equipment. Servicing of the fire equipment identified a replacement extinguisher was needed, and this was not actioned in a timely manner. An Electrical Installation Condition Report (EICR) was unsatisfactory, and recommended improvements had not been actioned due to confusion over whether action was needed. Portable Appliance testing (PAT) had not been carried out, and air conditioning units had not been serviced. Following the inspection, we received confirmation that PAT and electrical remedial work had been arranged.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. We saw some out-of-date emergency medicines that had not been disposed of in line with guidance. Following our inspection, we received confirmation that these had been safely disposed of.

The premises were visibly clean, and on the whole, well maintained and free from clutter. However, we noted that the floor to wall seals in one surgery were not intact, which could compromise effective cleaning, and there was a large amount of gypsum waste and patient information in cardboard boxes in an office and storeroom. Following the inspection, we received confirmation that repairs to the surgery flooring had been arranged.

The practice had effective arrangements to ensure the safety of the X-ray equipment. The required radiation protection information was available. However, evidence of 3-yearly performance checks of the X-ray units was not seen on the day of inspection. The provider submitted these after the inspection, which showed they had been completed before our visit and were satisfactory.

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

Hazardous substances were clearly labelled and stored safely.

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 for agency or locum staff. These reflected the relevant legislation but there were 2 different versions, and they 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 always available. For example, where Hepatitis B immunity (titre levels) was not available for 2 staff members, there was no risk assessment in place; we did not see right to work information for 9 staff members; a full employment history, satisfactory evidence of conduct in previous employment and satisfactory information about any physical or mental health conditions was not available for any staff.

Staff had the skills and experience to carry out their roles. However, we identified some gaps in their knowledge.

The practice did not have effective arrangements to ensure staff training, including continuing professional development (CPD), was up to date and reviewed at the required intervals. The provider was not able to evidence that all clinical staff had completed CPD relevant to their roles including; safeguarding adults and children, medical emergencies, and complaints handling, which are recommended by the General Dental Council (GDC). We saw additional gaps in training for fire safety, Legionella, the Mental Capacity Act and for learning disability and autism which is legally required for healthcare workers. Following the inspection, we received evidence that some staff had completed some of the required training, but gaps remained in all topics.

Staff told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed and knew how to escalate safeguarding concerns within the practice and externally.

There were effective 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 annual appraisals, practice team meetings and ongoing informal discussions.

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

Newly appointed staff had an appropriate role specific structured induction.

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

The practice had infection control procedures that reflected published guidance but were not always being followed.

Staff demonstrated knowledge and awareness of infection prevention and control processes, but not all could evidence they had received appropriate training.

The practice had ineffective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment was available but had not been completed in line with current guidance to evidence that the associated risks had been assessed, or that appropriate control measures and recommendations were in place. A previous risk assessment seen, which was carried out in line with guidance, was no longer appropriate due to changes within the building. The provider confirmed a new Legionella risk assessment had been carried out after the inspection and they were working through the recommendations.

The practice completed infection prevention and control (IPC) audits, but these were not reflective of practice or in line with current guidance. For example, audits were not completed at recommended intervals and did not include action plans.

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

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.