Ortho Limited t/a Cheyne Walk Orthodontics

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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 and had not taken into consideration appropriate guidance. During our assessment of this key question, we found concerns related to: The safety of the premises and equipment, adequacy and availability of emergency equipment. The recruitment processes of staff, training of staff, staff support and development. Infection prevention and control standards not being followed. This resulted in breaches 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.

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 did not know how to respond to a medical emergency and had not 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. However, we found several broken items and a treatment room to be in poor condition. Broken items included the upholstery of a dental treatment chair, a patient spittoon, a clinical waste bin held together with tape, an autoclave and a door handle. We also found loose electrical wires present in the basement area used by staff. We were not assured the processes were effective to identify and manage risks in relation to water, fire, health, and safety. We asked staff how they identified and managed risks in relation to Legionella, or other bacteria developing in water systems. Staff told us they completed temperature checks on taps, weekly flushing of low use water outlets and visual checks. However, we were not provided with evidence of these checks and found heavily scaled taps present around multiple areas in the practice, which can harbour bacteria. Staff were not aware of the products they used to manage the dental unit water lines and only 1 of 9 staff had completed training in Legionella. Staff said not all of them had completed fire training, but they did conduct regular checks of fire safety equipment. However, we viewed the fire logbook and found staff had not regularly checked the emergency lighting and smoke detector since November 2019. Staff were required to take instruments in a transportable box to the basement at least twice daily. This area posed a significant risk of slips, trips, and falls due to the steep, curved steps and limited handrails, which was not highlighted in the practice risk assessment.

Emergency equipment and medicines were not all available. We found multiple items of emergency equipment that had expired in 2021, such as Oxygen face masks and adult defibrillator pads. Equipment was not checked in accordance with national guidance. Following the assessment, the provider submitted evidence that replacement equipment had been ordered. The emergency equipment and medicines were kept in a locked cupboard accessed via a code. Staff could not access these in a timely way. The premises were visibly unclean, poorly maintained and cluttered. Cleaning of areas including the decontamination room and patient toilet required improvement. We found limescale build-up on multiple taps and sinks, dusty extractor fans, a soiled reusable patient bib and cobwebs present. Surfaces and flooring in the clinical area were not in line with the Department of Health publication ‘Health Technical Memorandum 01-05: Decontamination in primary care dental practices’ (HTM01-05). Following the inspection, the provider submitted evidence that the practice had cleaned areas. The basement area was partitioned into areas used by staff to store their personal belongings, as a laboratory and decontamination room. There was an unpleasant odour caused by a disused shower drain. We did not see satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions. For example, the servicing of the compressor, electrical safety testing and the Electrical installation condition report. Fire safety equipment was not serviced and well maintained. There was no evidence of the fire alarm and emergency lighting being serviced. We were told the practice purchased new fire extinguishers annually but were not provided with evidence, such as historic invoices to confirm this. Following our assessment the practice serviced the extinguishers on 28 June. Hazardous substances were clearly labelled and stored safely.

The practice did not ensure equipment was safe to use, maintained and serviced according to manufacturers’ instructions and the facilities were not maintained in accordance with regulations. We found multiple broken items of equipment around the practice and hazardous facilities in a poor state of repair. The management of fire safety was not effective. A fire safety risk assessment was carried out in line with the legal requirements. However, this did not accurately reflect the process in place as it stated the fire alarm, emergency lighting and equipment was regularly serviced. We were not provided with evidence of the servicing. The risk assessment also stated the practice had a satisfactory 5 yearly electrical installation certificate and electrical safety testing of electrical equipment. We were not provided with evidence of these and found multiple loose and exposed wires around the practice. The practice had arrangements to ensure the safety of the X-ray equipment. This included cone-beam computed tomography (CBCT) equipment. The required radiation protection information was available. However, this needed updating to reflect processes in place. We were not provided with training records for all staff using the X-ray equipment or CBCT machine. We did not see evidence of radiograph audits being carried out 6-monthly in line with recognised guidance. The last audit completed was dated September 2023. The practice had implemented some systems to assess, monitor and manage risks to patient and staff safety. This included sharps safety. The practice staff had not received training on sepsis, which would enhance their ability to identify signs of sepsis, differentiate it from other conditions and better equipped them to implement effective treatment plans, including the administration of antibiotics. The practice had risk assessments to minimise the risk that could be caused from substances that are hazardous to health.

Prior to the assessment, CQC received 3 “give feedback on care” responses with negative concerns relating to staffing.

Staff we spoke with did not have the skills, knowledge and experience to carry out their roles. Staff told us that there was not sufficient staffing levels for the oversight of staff and the practice. The provider confirmed they were aware and were actively recruiting for a CQC registered manager. Although staff knew their responsibilities for safeguarding vulnerable adults and children and were aware of how safeguarding information could be accessed, the practice did not ensure staff had completed safeguarding training to the appropriate level or updated their training at appropriate intervals. The practice also did not have the correct information available for staff in relation to safeguarding vulnerable adults and children. For example, the safeguarding policy detailed a previous employee who had left the practice as the safeguarding lead, and wrong contact details to raise concerns. The provider submitted an updated policy following the assessment. Staff did not receive a structured induction programme. There was no evidence that the induction included familiarising staff with safeguarding arrangements, and fire and medical emergency procedures. Staff told us they discussed their training needs during annual appraisals. They also discussed learning needs, general wellbeing and aims for future professional development.

We found there were ineffective systems to ensure recruitment procedures included all necessary information. We reviewed 8 staff recruitment records of which 4 staff did not have satisfactory evidence of conduct in previous employment as references were not always present. Four staff members did not have evidence of a full employment history or evidence of vaccinations. We found 3 staff members had a basic Disclosure and Barring Service (DBS) check and not an enhanced check as per requirements. We were not provided with evidence of a DBS check for 1 staff member and no risk assessment was in place to identify and mitigate associate risks. The practice had not ensured all clinical staff were qualified and registered with the General Dental Council (GDC). We did not see evidence that 3 clinical staff had appropriate professional indemnity cover. Newly appointed staff did not have a structured induction. The practice did not have arrangements to ensure staff training was up-to-date and reviewed at the required intervals. Clinical staff did not complete continuing professional development required for their registration with the GDC.

Staff told us how they ensured the premises and equipment were clean and well maintained. Our findings did not reflect this. Staff were not aware of who the infection control lead was. An infection control lead ensures there is a dedicated individual focused on maintaining high standards of hygiene and safety. Following our assessment, the provider told us a new infection control lead had been appointed. Staff did not always demonstrate knowledge and awareness of infection prevention and control processes. Staff told us that single use items were not reprocessed.

The practice did not appear clean in certain areas, such as the patient toilet, decontamination room and staff areas and there was an ineffective schedule to ensure it was kept clean. Staff did not follow infection control principles, including the use of personal protective equipment (PPE). The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. However, improvements were required to ensure waste was disposed of safely, such as consideration of foot operated bins to reduce cross contamination. We observed the decontamination of used dental instruments. This did not fully align with national guidance. The enzymatic solution used to disinfect instruments was not measured to ensure the dilution recommended by the manufacturer was achieved. There were no systems in place for monitoring the use of heavy-duty gloves and long handled brushes. We did not see staff wearing the appropriate PPE for decontaminating dental instruments, such as masks and protective eyewear. The light magnifier used to check if instruments were visibly clean was dirty. Sinks, taps, work surfaces used within the decontamination processes were visibly dirty, and cobwebs were present on walls. We found multiple instruments which appeared rusty or soiled with cement. The provider submitted photographic evidence after our assessment that these areas had been cleaned, the heavy-duty gloves and long handled brushes replaced, and a new system had been implemented to monitor their usage. Treatment rooms had missing tiles and cracked flooring. Surfaces that are not impervious and easily cleanable can impact on effective cleaning.

The practice completed Infection prevention and control (IPC) audits in line with current guidance. This did not accurately reflect processes, highlight concerns or drive improvement. The IPC audit completed 19 June 2024, stated there was no separate decontamination room and not all testing records were available for the washer disinfector. The practice had a separate decontamination room and did not use a washer disinfector. The audit failed to identify areas of concerns found during our assessment. The IPC policy had not been adapted to reflect the practice, the processes in place nor the equipment used. We were not satisfied that the policy contained an adequate IPC procedure that staff could follow to ensure the risks arising from infections were sufficiently prevented and controlled. The practice had a legionella risk assessment which was completed by an external company on 2 December 2019. This detailed control procedures to reduce the risk of legionella including removal of limescale and regular flushing of low use taps. We were not provided with evidence of implementation of weekly flushing. We found a shower head with heavy limescale and an unpleasant smell. We observed multiple heavy scale depositions on the outlets around the practice.

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