Deansgate Dental Studio

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• 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: safe and effective staffing/recruitment of staff which resulted in a breach of Regulation 19 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 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.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year. Staff we spoke with told us that equipment and instruments were well maintained and readily available. The provider described the processes they had in place to identify and manage risks. Staff felt confident that risks were well managed at the practice, and the reporting of risks was encouraged.

Emergency equipment and medicines were available and checked in accordance with national guidance. Staff could access these in a timely way. Portable suction was missing on the day of assessment. This was ordered immediately. The premises were clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely. We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. Fire exits were clear and well signposted, and fire safety equipment was serviced and well maintained.

The practice ensured equipment was safe to use and maintained and serviced according to manufacturers’ instructions. The practice ensured the facilities were maintained in accordance with regulations. A fire safety risk assessment was carried out in line with the legal requirements. The management of fire safety was not effective. Prior to our assessment the practice had never carried out a fire drill. A fire drill was carried out on 17 July 2024, all staff names and the evacuation time was recorded. The emergency lighting had not been serviced since the practice opened in January 2024. The practice manager booked the service for 26 July 2024. The practice had arrangements to ensure the safety of the X-ray equipment and the required radiation protection information was available. This included cone-beam computed tomography (CBCT), orthopantomogram (OPG) and handheld X-ray equipment. The practice had carried out risk assessments in relation to the safe storage and handling of substances hazardous to health, however this only covered 10 substances. The practice had no access to safety data sheets. We discussed this with the practice manager and were assured this would be rectified within the next 4 weeks. The practice had implemented systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety, sepsis awareness and lone working. The sharps risk assessment did not reflect procedures we observed on the day of assessment. Two sharps risk assessments were completed on 17 July 2024. Sharps bins were not clearly labelled when opened or closed. Labels were completed by a dental nurse during the assessment day. The practice had systems for appropriate and safe handling of medicines. Antimicrobial prescribing audits were carried out.

At the time of our assessment, the patients we asked felt there were enough staff working at the practice. They were able to book appointments when needed.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels. Staff stated they felt respected, supported and valued. They were proud to work in the practice. Staff discussed their training needs during annual appraisals, practice team meetings and ongoing informal discussions. They also discussed learning needs, general wellbeing and aims for future professional development. Staff we spoke with demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children. Staff told us they had received a structured induction programme, which included safeguarding.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff, however the policy did not meet the requirements of schedule 3 and they were not always followed. We noted that pre-employment checks, including DBS (Disclosure and Barring Service) and references were not carried out for 8 of the practice staff before they commenced employment at the practice. Hepatitis B titre levels (to indicate antibodies related to the virus) were not kept for 6 of the clinical staff. Eight of the clinical members of staff had no evidence of an induction to the practice. We saw no evidence that any member of staff had completed a medical health questionnaire. We discussed this with the principal dentist and practice manager, they planned to contact occupational health to attain the titre levels for those members of staff who did not have them. Recruitment risk assessments were completed for 5 members of staff; these risk assessments do not fully mitigate the risk of not carrying out full employment checks. The practice ensured clinical staff were qualified, registered with the General Dental Council (GDC) and had appropriate professional indemnity cover. Newly appointed staff had a structured induction, and clinical staff completed continuing professional development required for their registration with the General Dental Council. Two members of clinical staff did not have the correct level of safeguarding training for their role. All outstanding training was completed on 17 July 2024. The practice had arrangements to ensure staff training was up-to-date and reviewed at the required intervals. We saw the practice had effective processes to support and develop staff with additional roles and responsibilities.

Patients told us that the practice looked clean, and equipment appeared to be in a good state of repair.

Staff told us how they ensured the premises and equipment were clean and well maintained. They demonstrated knowledge and awareness of infection prevention and control processes. Staff told us that single use items were not reprocessed.

The practice appeared clean and there was an effective schedule in place to ensure it was kept clean. Staff followed infection control principles, including the use of personal protective equipment (PPE). Hazardous waste was segregated and disposed of safely. We observed the decontamination of used dental instruments, which aligned with national guidance.

The practice had infection control procedures which reflected published guidance and the equipment in use. Staff had appropriate training, and the practice completed Infection prevention and control (IPC) audits in line with current guidance. The practice had procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment. The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance.

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