Dental Department - University of East Anglia

We carried out this announced inspection on 21 September 2021 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 CQC inspector who was supported by a specialist dental adviser.

As part of this inspection we asked the following questions:

• Is it safe?

• Is it effective?

• 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 that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

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

Are services well-led?

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

Background

Dental Department- University of East Anglia is a well-established practice that offers NHS treatment to students and staff of the university. It is based in the university’s campus and has two treatment rooms. The dental team includes three dentists, four dental nurses, and a practice manager, all of whom are employed directly by the university. The practice is situated in a building shared with a GP practice and is fully accessible to wheelchair users.

The practice is open Monday to Friday from 9am to 5pm.

The practice is registered as a company and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at the practice is the practice manager.

On the day of inspection, we spoke with the practice manager, a dentist and three dental nurses. We looked at practice policies and procedures and other records about how the service was managed.

Our key findings were:

• The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had systems to help them manage risk to patients and staff.
• Staff felt respected, supported and valued.
• Systems for obtaining patient feedback about the service were good.
• There were limited systems in place to assess and monitor the quality of service provision and clinical care.
• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures which reflected published guidance.
• Comprehensive procedures had been implemented to reduce the spread of Covid-19.

We identified regulations the provider was not meeting. They must:

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

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

• Ensure that appropriate checks are completed prior to agency staff commencing employment at the practice.

• Implement local safety standards for invasive procedures to prevent wrong site dental extractions.

• Implement an effective system for monitoring and recording the fridge temperature to ensure that medicines and dental care products are being stored in line with the manufacturer’s guidance.