Coven Dental Surgery - Codsall

We carried out this announced inspection on 4 February 2020 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 provider 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 two specialist dental advisers.

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:

Are services safe?

We found this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Coven Dental Surgery – Codsall is in Codsall, Wolverhampton 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. Car parking spaces, including dedicated parking for people with disabilities, are available in the practice car park.

The dental team includes four dentists, two dental nurses, two trainee dental nurses, one receptionist and a practice manager. The practice has three treatment rooms.

The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.

On the day of inspection, we collected 47 CQC comment cards filled in by patients.

During the inspection we spoke with two dentists, one dental nurse, one receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday from 9am to 5pm.

Our key findings were:

• The practice appeared to be visibly clean, maintenance work was being carried out on the upstairs staff toilet.
• The provider had infection control procedures which reflected published guidance. We noted inconsistency in staff following the practice policy and processes when undertaking manual cleaning of the dental instruments. These shortfalls were rectified within 48 hours of this inspection.
• Staff knew how to deal with emergencies. Appropriate medicines and most life-saving equipment were available with some exceptions. Missing items were ordered by staff straight after our inspection.
• The provider had some systems to help them manage risk to patients and staff. We found shortfalls in appropriately assessing and mitigating risks in relation to electrical wiring testing, infection control processes, antimicrobial prescribing, radiography, legionella and fire. Immediate action was taken within 48 hours of our inspection to address most of these shortfalls.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. However, the practice did not have a safeguarding vulnerable adults policy and no safeguarding vulnerable adults training was viewed for the safeguarding lead. A copy of a newly implemented policy and recently completed training was sent to us within 48 hours of our inspection.
• The provider had staff recruitment procedures which reflected current legislation.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and 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.
• The provider had a culture of continuous improvement. Online training was funded and provided for all employed staff alongside some in house training.
• Staff told us they felt involved and supported and worked as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had information governance arrangements.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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