Friar Street 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 they have been put right by the provider. The impact of our concerns, in terms of the safety of clinical care, is minor for patients using the service. Once the shortcomings have been put right the likelihood of them occurring in the future is low. During our assessment of this key question, we found concerns related to the safety of the premises, adequacy and availability of emergency equipment and medicines, recruitment, and training, support and development of staff, and the infection prevention and control standards being followed at the practice. This resulted in a breach of Regulations 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Whilst there are issues to be addressed, the impact of our concerns relate 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.

Emergency equipment and medicines were not managed effectively and checked in accordance with national guidance. Expired medical equipment was present in the emergency medical kit. The emergency kit was located in 4 areas over 2 floors of the practice. Logs of checks did not reflect the stock of emergency medicines and equipment in any of the 4 areas they were stored in. Three out of date biohazard spillage kits were available for staff to use. Pocket masks were not available. Portable suction marked as 'not available' was available. Records to confirm that the defibrillator (AED) was checked, at least weekly, was not available. Records to confirm that oxygen and emergency equipment was checked, at least weekly, was not available. Glucagon was stored in a fridge. The fridge was not monitored to ensure its’ temperature remained between 2 and 8 degrees Celsius. Sedation medicines were stored securely but a system was not in place to monitor their use. Hazardous substances stored in the decontamination room were not stored in line with the control of substances hazardous to health (COSHH) regulations. COSHH risk assessments and COSHH safety data sheets were not available for every COSHH identified product used in the practice. A clinical waste bin, stored on the fire escape route, was not secured to prevent unauthorised access and interference. The fire exit routes from the fi

The practice had not implemented systems to assess, monitor and manage risks to patient and staff safety. Records to confirm that emergency lights were tested and serviced appropriately were not available. Records to confirm that fire drills were carried out were not available. A fire safety risk assessment was carried out by someone who could not demonstrate competency in the management of fire safety. We have since received evidence to confirm that a company has been appointed to carry out a fire risk assessment. Local radiography rules did not reflect current practice. X-ray equipment was left switched on when treatment rooms were vacated. Operators remained in controlled areas while x-rays were taken. Rectangular collimators were not present on the x-ray equipment in treatment rooms 2 and 4. Records to confirm that performance checks for the x-ray equipment in treatment rooms 2, 4 and 5 had been carried out were not available. Records to confirm that the air conditioning units had been serviced was not available. The annual service for 1 was due in April 2024. A lone working risk assessment had not been carried out for hygienists who worked without chair side support.

The practice had a recruitment policy and procedure to help them employ suitable staff but checks had not been carried out in accordance with relevant legislation. A foundation dentist worked with a student dental nurse who was not registered or qualified. Records of Hepatitis B antibody levels for 11 clinical staff were not available. This was contrary to the practice's sharps risk assessment. Improvements could be made to take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases. The practice did not have systems in place to ensure all staff had completed training as per recommended national guidance. Basic life support training was completed by 19 out of 20 staff in the previous 12 months. Infection prevention and control training was completed by 9 out of 17 clinical staff. Safeguarding children training was completed by 12 out of 20 staff. Safeguarding vulnerable adults training was completed by 13 out of 20 staff. Three staff who completed training did not undertake the required level for their roles. Fire safety training was completed by 15 out of 20 staff in the previous 12 months. Interacting with people with a learning disability and autistic people training was completed by 13 out of 20 staff. The practice ensured clinical staff were registered with the General Dental Council. Evidence of current indemnity was not available for 3 clinicians. The practice offered conscious sedation for patients. We found the practice did not have systems to do this safely. The practice did not have appropriate emergency equipment and medicines. Evidence of immediate life support (or basic life support plus patient assessment, airway management techniques and AED training) for both the operator and clinician supporting treatment was not available. Evidence of 12 hours verifiable sedation related training (5-year cycle) for both the operator and clinician supporting treatment was not available.

The practice did not have effective infection control procedures which reflected current published guidance. A low volume suction unit in treatment room 5 was seen to be repaired with tissue and Sellotape. The floor seals in treatment room 1 and 4 were not impervious. The seals around dental chairs in treatment rooms 1 and 4 were not impervious. A foot operated clinical waste bin was not available in treatment room 1. Unsealed local anaesthetic ampules were seen in treatment room drawers. Needle guards were not available in any treatment rooms. This was contrary to the practice's sharps risk assessment. Clinical sharps bins were positioned close to the floor in treatment rooms 1 and 4. This was contrary to the practice's sharps risk assessment. Sharps were transported from treatment rooms to the decontamination room for disposal. This was contrary to the practice's sharps risk assessment. Treatment room cleaning checklists were not completed appropriately. A non-clinical area cleaning mop and bucket was used to clean treatment rooms. This was confirmed by the person who cleaned the practice. Staff audited their own standards of cleaning. Staff manually cleaned instruments before placing them in a steriliser. Staff were unaware of the correct water temperature required for this task. The cleaning agent dilution ratio was not measured. A log of water temperatures was available but not completed. A manual cleaning brush and glove replacement process was not in place. Endodontic files were used to unblock dirty instruments. A wire metal brush was used to clean instruments. Used dental treatment instruments were not kept moist in an appropriate way while they waited to be re-processed.

Records to confirm that routine vacuum autoclave validation checks had been carried out were not available. One logbook was used to record validation check results for three machines. We were told that the data loggers on all 3 autoclaves did not work. Records to confirm that weekly air leakage tests, for every autoclave, had been carried out were not available. Instruments were not spaced out on trays to prevent overloading when being sterilised. Water temperature monitoring was carried out with a mercury thermometer. We have since received evidence to confirm this shortfall has been addressed. A legionella risk assessment was carried out on 6 September 2024. The resulting actions required from this assessment remained outstanding at the time of our visit. Staff told us that the hot water did not reach the required temperature but actions to rectify this issue remained. An annual infection prevention and control statement was not available.

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