Updated 1 November 2023
We carried out this announced comprehensive inspection on 11 October 2023 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.
We planned the inspection to check whether the registered practice was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations.
The inspection was led by a Care Quality Commission (CQC) inspector who was supported by a specialist dental advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The dental clinic appeared clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and most life-saving equipment were available.
- The practice had systems to manage risks for patients, staff, equipment and the premises. However, we identified shortfalls in assessing and mitigating risks in relation to legionella and medicines management.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation, although this had not always been followed. Required pre-employment checks including checks of qualifications had not always been obtained for new staff.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved, supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
34 Dental is in Oadby, Leicestershire and provides private dental care and treatment for adults and children.
The practice treatment rooms are on the first floor and are accessed by stairs. People who use wheelchairs or are unable to climb stairs are directed by practice staff to other local services.
Car parking spaces, including dedicated parking for disabled people, are available near the practice.
The dental team includes 7 dentists (4 of whom specialise in prosthodontics, oral surgery, periodontics and orthodontics) 2 qualified dental nurses, 1 trainee dental nurse, 1 dental therapist and 1 receptionist. The practice has 2 treatment rooms.
During the inspection we spoke with 2 dentists, 1 qualified dental nurse, 1 trainee dental nurse, 1 receptionist and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Friday from 8.30am to 5.30pm.
Saturday twice per month from 8.30am to 5.30pm.
There were areas where the provider could make improvements. They should:
- Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Implement an effective system for identifying, disposing and replenishing of stock.
- Implement an effective system of checks of medical emergency equipment taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ In particular ensuring temperatures of taps reached the required level.