Updated 11 December 2023
We carried out this announced comprehensive inspection on 29 November 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 were available. Two items of life-saving equipment were not available, these were obtained immediately.
- The practice had systems to manage risks for patients, staff, equipment and the premises. We highlighted a minor risk in relation to radiation protection.
- 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 provider could not provide evidence that some pre-employment checks were carried out.
- 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
Southwell Dental Care is in the Southwell in north Nottinghamshire and provides mainly NHS dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available at the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 3 dentists, 4 dental nurses including 2 trainee dental nurses and 2 receptionists. The practice has 2 treatment rooms, both of which are on the ground floor.
During the inspection we spoke with 2 dentists, 2 dental nurses and 1 receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open: Monday to Friday: from 9am to 5:30pm.
There were areas where the provider could make improvements. They should:
- Review the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, take account of any actions and recommendations identified in the critical examinations for the equipment, to ensure the equipment is being operated safely.
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. Ensure all of the documentation required by Schedule 3 of the Health and Social Care Act 2008 Regulations are in place for every member of staff at the practice.
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.