Mrs E Dimitrijevic - Dental Surgery

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well led care in accordance with the relevant regulations. The provider had made insufficient improvements to put right the shortfalls and had not responded to the regulatory breaches we found at our inspections on 11 January 2024 and 19 March 2024. We have told the provider to take action. 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.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Staff and leaders told us of the systems in place to manage risks for patients, staff, equipment and the premises. At the assessment on 9 August 2024, we found the practice had made some improvements to comply with the regulation: All items of medical emergency kit that were previously not available have been purchased and were available for use. New systems and checks, including daily checks had been implemented to ensure availability and effectiveness of medical emergency equipment. Logs were kept, demonstrating checks had been completed. The provider had taken action to implement all recommendations in the Legionella risk assessment. For example, staff had completed Legionella training to ensure they were aware of their role and the procedures to follow, and hot and cold water temperatures were being monitored and logged. The boiler had been serviced. Fire safety checks had been implemented, such as weekly checks of the smoke alarm, fire extinguishers and emergency exit routes. Other fire safety equipment currently available at the practice is also subject to checks. A new fire safety policy had been developed and discussed with staff. A new compressor was in place. Staff had undertaken adult and child safeguarding training to level 3, a policy was now in place and safeguarding contact information was available. A radiography audit had been undertaken. A referral log was in place. However, there was scope to ensure the practice documented when patients had been referred. An Enhanced Disclosure and Baring service check had been completed for the dental nurse. Sharps bins were signed and dated, and a policy and sharps risk assessment were now in place. An electrical installation condition report had been undertaken on 3 May 2024.

At the assessment on 9 August 2024, we found the practice had made some improvements to comply with the regulation. However, some processes remain outstanding. A recent Electrical Installation Condition Report was undertaken on 3 May 2024. This was deemed unsatisfactory with several C2 (Category 2) actions identified. C2 actions indicate potentially dangerous issues. These are faults that are not immediately dangerous but could become hazardous if not addressed. We were not provided with dates or an action plan to address these immediate remedial work to eliminate potential risks. The practice were not dispensing antibiotics in line with current guidance. Staff were decanting dosages from bulk supplies and not providing patients with patient information leaflets. In addition, we noted patients were provided with 7 days of treatment as opposed to the recommended 5 days course of treatment. The practice were not undertaking antimicrobial audits There were no record keeping audits. We noted from the dental care records we looked at that justifying and grading of x-rays had not been recorded along with other areas of treatment. The dentist was not aware of current guidance. Following our inspection on 11 January 2024 and our follow up inspection on 19 March 2024, the practice had taken action to declutter the treatment room and remove dental instruments that were not stored in sterilized pouches. During our inspection on 9 August, we found repeated concerns to our previous inspection in January 2024. We found a number of dental instruments were not stored in line with guidance and treatment room shelves required decluttering. The provider told us this would be addressed.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.