Updated 14 March 2024
We carried out this announced comprehensive inspection on 13 February 2024 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. Appropriate medicines and life-saving equipment were available.
- The practice did not have systems to manage risks for patients, staff, equipment or the premises.
- 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 a lack of effective leadership or a culture of continuous improvement.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Kinver Dental and Implant Surgery is in Kinver and provides NHS and private dental care and treatment for adults and children.
There is step free 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 near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 4 dentists, 1 dental nurse, 1 trainee dental nurse, 1 dental therapist, 1 practice manager and 1 operations manager. The practice has 2 treatment rooms.
During the inspection we spoke with 2 dentists, 1 dental nurse, the practice manager, the operations manager and one of the practice partners. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Wednesday from 8.30am to 5.30pm.
Thursday from 8.30am to 6pm.
Friday from 8.30am to 5pm.
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:
- 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.