Updated 26 October 2022
We carried out this announced comprehensive inspection on 29 September 2022 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 adviser.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five 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 was visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance. However, monthly water temperature checks were not carried out in line with the legionella risk assessment.
- Staff knew how to deal with medical emergencies and most appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff. However, the dentist did not use rubber dam when carrying out root canal treatments.
- 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.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and 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 dental clinic had information governance arrangements.
Background
Shires Dental Practice is in Birmingham and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. The practice has made reasonable adjustments to support patients with additional needs. When the practice cannot fully accommodate patients with disabilities due to the layout of the building, staff refer patients to buddy practices nearby which are fully accessible.
The dental team includes 1 dentist, 2 dental nurses, 2 receptionists and 2 practice managers. The practice has 2 treatment rooms.
During the inspection we spoke with 1 dentist,1 dental nurse/practice manager and 1 receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday from 9.30am to 5.30pm
Friday from 9.30am to 12.30pm
There were areas where the provider could make improvements. They should:
- 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 monthly water temperature checks should be carried out.
- Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.