Antwerp House 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.

During our assessment of this key question, we found concerns related to ensuring that persons providing care or treatment to service users had the qualifications, competence, skills and experience to do so safely and ensuring that the equipment used by the service provider for providing care or treatment to a service user was safe for such use and used in a safe way. These resulted in a 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 report 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 knew how to respond to a medical emergency. However, there was no evidence that all staff had completed training in emergency resuscitation and basic life support every year.

Immediate life support training was completed by staff providing treatment to patients under sedation.

Emergency medicines and most equipment were available and staff could access these in a timely way. They were checked in accordance with national guidance. Improvements were required to ensure that these checks included all equipment advised in national guidance and that these checks were effective.

The premises were clean and well maintained. Hazardous substances were clearly labelled and stored safely.

The practice had several maintenance issues, including overdue servicing of equipment, lack of safety reports for electrical installations, and unresolved faults in air conditioning units. Additionally, there was no evidence of servicing for some medical devices, and staff were unaware of certain maintenance requirements. Temperature checks on the refrigerator used to store an emergency medicine were also not being completed.

A fire safety risk assessment had been carried out in line with the legal requirements in February 2023. The practice had several fire safety issues, including unaddressed recommendations from the fire safety risk assessment, lack of fire evacuation drills, insufficient fire training for staff, and inconsistent testing of fire alarms. Additionally, emergency lighting had not been serviced, and faulty fire extinguishers had not been fixed.

Regarding radiography and laser equipment, while some devices were serviced according to guidance, annual tests were not completed, and not all staff had necessary training. There was also no appointed advisor or policies for laser use, and post-inspection information did not assure proper rectification.

The practice had some risk assessments to minimise the risk that could be caused from substances that are hazardous to health. Improvements could be made to ensure that all necessary substances were included. Additionally, improvements could be made to simplify the system in place to enable staff to quickly locate the necessary information if needed.

The practice had implemented some systems to assess, monitor and manage risks to patient and staff safety. However, the health and safety risk assessment was not reflective of the practice. Following the inspection, the practice sent an updated health and safety risk assessment, yet this was still not completely reflective of the service. There was no lone worker’s risk assessment.

Improvements could be made to ensure prescriptions were stored safely. Antimicrobial prescribing audits were not carried out.

Staff we spoke with had the skills, knowledge and experience to carry out their roles. They told us that there were sufficient staffing levels.

Not all staff from whom we received feedback, said they felt supported, with some staff members feeling unheard, unvalued and stating that their concerns were not listened to. Staff commented that they would benefit if communication was improved in the practice.

Not all staff received feedback about their performance or an appraisal.

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.

The practice had a recruitment policy and procedure to help them employ suitable staff, including for agency or locum staff. However, we saw that this process and procedure had not always been followed by the practice. For example, not all staff had a Disclosure and Barring Service (DBS) certificate, not all clinical staff had evidence of immunity to Hepatitis B, and not all staff had identification or proof of right to work in the UK. Improvements were needed to ensure that current legislation was always followed when recruiting staff.

The practice did not always ensure that they had evidence to show that clinical staff were qualified, registered with the General Dental Council and had appropriate professional indemnity cover. Improvements were needed to ensure this was completed for all clinical staff members.

Newly appointed staff did not always have a documented structured induction. We saw that the practice was not aware if clinical staff had completed continuing professional development required for their registration with the General Dental Council.

The practice did not have arrangements to ensure staff training was up-to-date and reviewed at the required intervals. Improvements were required to ensure this was completed following this inspection.

The practice did not have a whistleblowing policy.

The practice appeared clean, however there was not an effective schedule in place to ensure it was kept clean, which was not in line with national guidance.

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 was maintained and serviced. Staff demonstrated knowledge and awareness of infection prevention and control processes, and we saw single use items were not reprocessed.

Not all staff had appropriate training in infection prevention and control (IPC). The practice completed an IPC audit, yet the frequency was not in line with current guidance. Additionally, the audit was not a true reflection of the practice and had multiple errors.

The practice did not have effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems. A risk assessment was completed in 2023 yet there was no evidence that actions had been completed. Additionally, monthly water temperature checks were not being carried out and there was no evidence that dental water lines were being flushed between patients as per guidance.

The practice had policies and procedures in place to ensure clinical waste was segregated and stored appropriately in line with guidance. Improvements could be made to ensure that waste consignment notes were obtained and stored.

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