Cotman House Dental Surgery

We carried out this announced focused inspection on 11 October 2022 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 adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask five key questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive?
• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

• The dental clinic was visibly clean and well-maintained.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• Staff felt involved and supported and worked well as a team.
• Patients were asked for feedback about the services provided.
• The dental clinic had appropriate information governance arrangements in place.
• Appropriate pre-employment references and Disclosure and Barring Service checks had not been obtained for new staff.
• Auditing and risk management systems within the practice were not effective in driving improvement.
• Overall governance systems in the practice needed to strengthen to ensure a safe service was provided.

Background

Cotman House Dental Practice provides mostly private dental care and treatment for adults and children. The Grade 2 listed building within which the practice is located, is not accessible for wheelchair users.

Car parking spaces are available at nearby public car parks.

The dental team includes a dentist, a nurse, a practice manager and a receptionist.

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

The practice is open on Tuesdays, Thursdays and Fridays from 9.40am to 5.30pm, and on Wednesdays from 10.20am to 6pm.

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

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

• Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.

• 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.

• Take action to ensure rubber dam is used protect patients’ airways during root canal treatment.

• Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.

• Improve and develop the practice's policies and procedures for obtaining patient consent to care and treatment to ensure they are in compliance with legislation and take into account relevant guidance.