Windlesham Dental Centre

We carried out this announced comprehensive inspection on 28 April 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 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 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 not 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

Windlesham Dental Centre is in Windlesham and provides 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 near the practice.

The dental team includes a dentist and a trainee dental nurse. The practice has one treatment room.

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 spoke with a dentist and a trainee dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

• Monday, Tuesday, Wednesday and Friday 8am to 2pm
• Saturday 9am to 1pm

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures which did not reflect published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not available.
• The provider had some systems to help them manage risk to patients and staff.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider did not have staff recruitment procedures which reflected current legislation.
• The clinical staff provided patients’ care and treatment in line with current guidelines, but patient dental care records must be improved to reflect this.
• 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 as a team.
• The provider asked staff but not patients for feedback about the services they provided.
• The provider had information governance arrangements.

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

• Ensure care and treatment is provided in a safe way to patients.

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

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

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

• Implement audits for prescribing of antibiotic medicines taking into account the guidance provided by the Faculty of General Dental Practice.

• Take action to ensure the availability of an interpreter service for patients who do not speak English as their first language.

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

• Take action to ensure the service takes into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.

We are mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.