Updated 3 April 2023
We carried out this announced comprehensive inspection on 21 March 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. Most medicines and life-saving equipment were available.
- Systems to manage risks for patients, staff, equipment and the premises were not always in place. Procedures to manage risk from legionella were not effective or embedded.
- 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 effective leadership and a culture of continuous improvement. However, required audits were not always completed within recommended timescales.
- Staff felt involved, supported and worked as a team.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
The provider has 1 practice, and this report is about Pennwood Dental Practice.
Pennwood Dental Practice is in Wolverhampton and provides NHS and private dental care and treatment for adults and children.
Due to the location of the practice, there is no step free access for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes 1 dentist and 4 dental nurses. The practice has 2 treatment rooms.
During the inspection we spoke with the dentist and 3 dental nurses. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday, Tuesday, Thursday and Friday from 9am to 6pm
Wednesday from 9am to 1pm
There were areas where the provider could make improvements. They should:
- Take action to ensure audits of radiography 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.
- Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals.
- Take action to implement and document any recommendations in the practice's fire safety and Legionella risk assessments to ensure ongoing risk management is effective.
- 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.