Ledbury Dental Care

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 the provider has made the required improvements. 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, training, support and development of staff and the infection prevention and control standards being followed at the practice. We also found concerns relating to the management of people's medicines and prescriptions. Improvements were needed to promote and embed a learning culture at the practice.

These concerns were in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can find more details of our concerns in the detailed 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.

The practice did not have all the necessary processes to identify and manage risks.

There were no effective systems for ensuring that expired items were removed or replaced from the medical emergency kit. We found self inflating bags with reservoirs (child and adult), needles, syringes and eyewash that had exceeded their expiry dates and multiple items such as masks and oropharyngeal tubes, in packaging with no There was no automated external defibrillator.

Staff knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Although staff were recording fridge temperatures to ensure the glucagon (a medicine which helps to raise blood glucose levels), was being stored at a temperature of 2–8°C in line with the manufacturer’s instructions, we noted there were numerous occasions where temperatures had exceeded the maximum temperature and no action had been taken.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were labelled and stored safely.

We did not see evidence of satisfactory records of servicing and validation of all equipment in line with manufacturer’s instructions. The electrical installation condition report had been completed for the first time immediately prior to our assessment. This should be carried out every 5 years. The electrical equipment testing was last carried out in 2020, and we did not see evidence the compressor had been serviced within the required time frame.

A fire risk assessment was carried out by a staff member who could not demonstrate fire safety management competence. There was no fire detection equipment and testing of emergency lighting was not effective. The provider did not require staff to complete fire training or take part in fire evacuations.

Systems for appropriate and safe management of medicines needed strengthening. Medicine labels did not have the name and address of the practice on them.

Although the provider mostly followed procedures that reflected relevant legislation; to help them employ suitable staff, the practice did not have an up-to-date recruitment policy to reflect this.

The practice ensured clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover.

Staff inductions did not cover the areas needed to inform new staff about practice policies and to provide suitable training when they started work so they could carry out their roles effectively.

There was no evidence to show all staff benefited from completing recommended training to ensure they had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient levels of staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice did not have arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals.

Although, staff discussed their, general wellbeing and aims for future professional development during practice team meetings and ongoing informal discussions, we discussed the benefit of offering annual appraisals to support and develop staff.

Staff stated they felt respected, supported and valued and they were proud to work in the practice.

The practice had infection control procedures that reflected published guidance.

We did not see evidence that all staff had received appropriate training. They did not demonstrate all the necessary knowledge and awareness of infection prevention and control processes.

We observed use of personal protective equipment, and the decontamination of used dental instruments did not consistently align with national guidance. There was no rinsing sink or bowl (this was being done under running water), dirty instruments were not transported in a closed box, personal protective aprons was not donned, instruments were cleaned with a long-handled brush without rinsing them under water and or a solution before placing them in the ultrasonic bath. Impression disinfection was carried out in the staff communal kitchen. The handwashing sink in the surgery had electric cables trailing across it.

We saw and staff confirmed that single use items were not reprocessed.

The practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance. A risk assessment was carried out by a staff member. Water temperatures were not recorded, the provider was unaware that water temperatures were required to reach 55 degrees and we did not see evidence the water lines were being flushed or purged.

Although the practice appeared clean there were no schedules in place to ensure effective cleaning. Clinical waste bags were not labelled with the practice name and address to ensure safe segregation and disposal of hazardous waste.

The equipment in use was maintained and serviced as per manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance, however these did not identify the shortfalls we found during our assessment.

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