Archived: Dundee Court Dental Centre

Updated 17 October 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection took place on 7 September 2016 and was conducted by a CQC inspector and a dental specialist advisor.

During the inspection we spoke with the owner, one dentist, a dental nurse and the receptionist. We received feedback from 23 patients who had completed our comment cards prior to our visit. We reviewed policies, procedures and other documents relating to the management of the service.

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 therefore formed the framework for the areas we looked at during the inspection.

Updated 17 October 2016

We carried out an announced comprehensive inspection on 7 September 2016 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well led?

Our findings were:

Are services safe?

We found that this practice was not 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

Dundee Court Dental Centre provides only private general dentistry services to adults and children and is owned by Dr Christopher Bird. It is situated on an industrial estate just outside Kings Lynn and serves about 2,200 patients.

The practice has a team of two dentists, three dental nurses, a practice manager and a receptionist. There are three treatment rooms, two rooms for the decontamination of instruments, an office, two patient waiting areas and a reception area.

The practice opens on Mondays to Thursdays from 8.30am to 5pm, and on a Friday from 8.30am to 4pm.

The practice owner is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

Our key findings were:

• We received consistently good feedback from patients about the quality of the practice’s staff and the effectiveness of their treatment.

• There was appropriate equipment for staff to undertake their duties, and most equipment was well maintained.

• There were sufficient numbers of suitably qualified and competent staff. Members of the dental team were up-to-date with their continuing professional development and supported to meet the requirements of their professional registration.

• Patients received clear explanations about their proposed treatment and were actively involved in making decisions about it. They were treated in a way that they liked by staff.

• Appointments were easy to book and emergency slots were available each day for patients requiring urgent treatment.

• Staff we spoke to felt well supported by the practice owner, despite his absence due to ill-health, and were committed to providing a quality service to their patients.

• The practice did not have access to an automated external defibrillator and the medical oxygen available on the premises was out of date.

• The practice did not have a structured plan in place to audit quality and safety beyond the mandatory audits for radiography

• Essential checks for gas safety and Legionella control had not been implemented.

We identified regulations that were not being met and the provider must:

• Implement robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.

• Ensure the availability of medicines and equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.

• Ensure the safety and suitability of all areas of the premises and the equipment within it.

• Ensure the practice implements the recommendations of its Legionella risk assessment.

• Ensure audits of various aspects of the service such as infection control are undertaken at regular intervals to help improve the quality of service. The practice should ensure all audits have documented learning points and the resulting improvements can be demonstrated.

• Ensure that all staff undertake relevant training, to an appropriate level, in the safeguarding of children and vulnerable adults.

• Ensure effective systems and processes are established to assess and monitor the service against the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and national guidance relevant to dental practice.

There were areas where the provider could make improvements and should:

• Review the storage of dental care products to ensure they are stored in line with the manufacturer’s guidance and the fridge temperature is monitored and recorded.

• Review the practice’s sharps handling procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

• Review the protocol for completing accurate, complete and detailed records relating to employment of staff. This includes making appropriate notes of interviews and ensuring references are obtained.

• Review the practice’s infection control procedures and protocols giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
• Review appraisal protocols to ensure that all staff working at the practice have their performance monitored and assessed.