St Leonard's House Dental Practice

We carried out this announced comprehensive inspection on 27 September 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 practice had infection control procedures which reflected published guidance, but improvements could be made.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to manage risks for patients, staff, equipment and the premises. Some repair to flooring and to address damp is required.
• 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.
• 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 a culture of 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

St Leonard’s House Dental Practice is in Bodmin and provides NHS and private dental care and treatment for adults and children.

There is a portable ramp for step free access to the practice and all treatment rooms are on the ground floor. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The building is listed, which imposes limitations on the extent the premises can be adapted to support patients with access requirements.

The dental team includes 1 dentist, 1 dental nurse, 1 trainee dental nurse and 2 receptionists. The practice has 2 treatment rooms.

During the inspection we spoke with the whole staff team. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open: Monday, Wednesday and Thursdays 9.00am – 4.30pm.

Tuesday and Fridays 9.00am – 3.00pm.

We identified a regulation the provider is not complying with. They must:

• Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. In particular by making repairs to damaged flooring in 2 areas at the practice and by managing mould growth from damp in staff and patient areas.

Full details of the regulation the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Improve the practice’s infection control procedures and protocols 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, by reviewing guidance for effective air flow inside the instrument cleaning and decontamination area.
• Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Take action to ensure audits of infection prevention and control, record keeping, antimicrobial prescribing are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.