Archived: Wednesfield Dental Practice

We undertook a follow up desk-based inspection of Wednesfield Dental Practice on 10 March 2020. This inspection was carried out to review in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The inspection was led by a CQC inspector.

We undertook a comprehensive inspection of Wednesfield Dental Practice on 9 July 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well-led care and was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can read our report of that inspection by selecting the 'all reports' link for Wednesfield Dental Practice on our website www.cqc.org.uk.

As part of this inspection we asked:

• Is it well-led?

When one or more of the five questions are not met we require the service to make improvements and send us an action plan (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

Our findings were:

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 9 July 2019.

Background

Wednesfield Dental Practice is in Wolverhampton and provides NHS and private treatment for adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available immediately outside the practice in their own car park, but there are no designated spaces for blue badge holders.

The dental team includes five dentists, seven dental nurses (two of whom are trainee dental nurses), one receptionist and a compliance manager. There is also an area manager who oversees all management and compliance. The practice has three treatment rooms and a separate room for carrying out decontamination.

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.

During the inspection, we looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday: 9am to 5pm

Saturday/Sunday/Bank holidays: 9am to 12pm (emergencies only).

Our key findings were:

• Improvements had been made in the practice’s systems for completed audits, training and recruitment.
• Improvements had been made in the management of medical emergencies.

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

• Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England. This had improved since our previous visit but the alerts were not being checked daily.

We carried out this announced inspection on 9 July 2019 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.

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 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 caring?

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

Are services responsive?

We found that this practice was providing responsive 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

Wednesfield Dental Practice is in Wolverhampton and provides NHS and private treatment to adults and children.

There is level access for people who use wheelchairs and those with pushchairs. Car parking spaces are available immediately outside the practice in their own car park but there are no designated spaces for blue badge holders.

The dental team includes five dentists, five dental nurses, one practice manager and one receptionist. The practice has three treatment rooms and a separate room for carrying out decontamination.

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 12 CQC comment cards filled in by patients. We spoke with two dentists, two dental nurses, 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: 9am to 5pm

Saturday/Sunday/Bank Holidays: 9am to 12pm (emergencies only).

Our key findings were:

• The practice appeared clean and well maintained.
• 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.
• Staff felt involved and supported and worked well 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 suitable information governance arrangements.
• The provider had infection control procedures which reflected published guidance although we identified some necessary improvements.
• Appropriate medicines and life-saving equipment were available. Staff training in the management of medical emergencies was significantly overdue.
• The practice had limited systems to help them manage risk to patients and staff.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children. Several staff members had not completed training to the recommended level.
• The provider’s staff recruitment procedures required improvements.
• Immunisation records were missing for some staff members.

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 is not meeting are at the end of this report.

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

• Review the practice’s protocols for domiciliary visits taking into account the 2009 guidelines published by British Society for Disability and Oral Health in the document “Guidelines for the Delivery of a Domiciliary Oral Healthcare Service”.
• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review the practice’s system for recording, investigating and reviewing incidents with a view to preventing further occurrences and ensuring that improvements are made as a result.
• Review the practice's protocol and staff awareness of their responsibilities in relation to the duty of candour to ensure compliance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.