Friars 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. 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, 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, 17, 18 and 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 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.

We were not assured that staff knew how to respond in an emergency, during discussions with staff there was limited knowledge and understanding of how to use the medical emergency equipment and medicines. We were not assured all staff had completed training in emergency resuscitation and basic life support every year. We were not assured all staff had completed training in fire safety and emergency evacuation of the practice. Staff we spoke with could not confirm they had undertaken any fire safety training and we did not see evidence of fire safety training for any of the 17 members of staff.

There were no effective systems for ensuring that expired or used items were removed or replaced from the medical emergency kit. We found multiple items that had expired, these included; oropharyngeal airways sizes 1, 2 and 3 which had expired in July 2022, the oropharyngeal airway size 4 had expired March 2023 and the oropharyngeal airway size 0 had expired April 2024. Following the assessment the provider confirmed these had been replaced. We were not assured systems to ensure the safety of the premises were effective. We were not provided with a copy of the Electrical Installation Condition Report which we were told was undertaken in 2020. Fire exits were clear and signposted, and fire safety equipment was serviced. Records were not available to demonstrate the servicing and maintenance of equipment including the washer disinfector, ultra sonic bath, autoclaves, compressor and X-ray units. Following the assessment evidence that these had been undertaken after our visit was submitted. We saw evidence of portable appliance testing through the stickers on equipment, however a certificate to demonstrate that every item of equipment had been tested was not available.

The practice systems to ensure equipment and facilities were safe to use, maintained and serviced according to manufacturers’ instructions were not effective. The practice could not demonstrate that a comprehensive fire safety risk assessment had been undertaken by a trained and competent individual. There was limited evidence that fire safety equipment, such as smoke alarms were checked in line the legal requirements. Fire drills were not undertaken regularly. We were not assured that the management of fire safety was effective. The required radiation protection information was not in place, we were shown an email from the Radiation Protection Advisor (RPA) in May 2024. This included a number of attachments, documents and reports from the latest (5 March 2024) inspection undertaken by the RPA of the practice radiation equipment. We noted numerous action points from the radiation performance report that were not actioned. As a result, we could not be assured the systems in place for the safe use of X-ray equipment were effective or compliant with legal requirements. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health (COSHH). These were not easily accessible to the cleaner or practice staff as these were locked in the practice manager’s office and only the registered manager had access to the keys. We reviewed the arrangements for medicines management in the practice. We found there were no logs of medication stock including the 3 antibiotics dispensed by the practice and no log of prescriptions. Prescription only medication was not stored securely, and we noted a loose box of an antibiotic (amoxicillin) in one unlocked treatment room drawer, local anaesthetics were not stored in blister packs. Antimicrobial prescribing was not in line with the current Faculty of General Dental Practice Antimicrobial Prescribing in Dentistry 2020 guidance.

Not all the staff we spoke with demonstrated knowledge of safeguarding or were aware of how safeguarding information could be accessed. Staff knew their responsibilities for safeguarding vulnerable adults and children, but were not confident in what action they should take or how. The provider told us staff received a structured verbal induction programme, which included safeguarding. However, there was no documented evidence to support this process.

The practice had a recruitment policy and procedure to help them employ staff. We found that systems to monitor and track the recruitment of staff including visiting staff, such as locum dental nurses, were ineffective as information was not readily available. This meant we were unable to ascertain if the practice was implementing its own recruitment policy and meeting these requirements. Arrangements to ensure staff training was up-to-date and reviewed at the required intervals was not in place. We were told clinical staff completed continuing professional development (CPD) required for their registration with the General Dental Council. We asked for and were not provided with evidence of completed CPD for the clinical team members. There was limited evidence of training for other staff including reception staff and trainee dental nurses. Processes to support and develop staff with additional roles and responsibilities were either not in place or not made available when asked for during the assessment.

The practice appeared clean and there were schedules 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.

Staff demonstrated knowledge and awareness of infection prevention and control processes and we saw single use items were not reprocessed. The practice could not demonstrate that a comprehensive Legionella risk assessment had been undertaken by a trained and competent individual. The practice procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment were not in place. Records of water temperature or other water testing were not provided. We observed scale deposits on the outlets in the ground floor rear treatment room. 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.