We carried out an unannounced comprehensive inspection on 9 November 2015 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
Freshbrook Dental Practice Limited provides private treatment and caters for both adults and children and has two dentists, a part time dental hygienist and six supporting staff. The practice is situated in a converted commercial property. The practice had three dental treatment rooms and a separate decontamination room for cleaning, sterilising and packing dental instruments and a reception and waiting area.
The practice owner is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. 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.
We carried out an unannounced comprehensive inspection on 9 November 2015 due to information of concern being shared with the Care Quality Commission. The inspection was carried out by a lead inspector and a dental specialist adviser.
Our key findings were:
- The practice had systems to assess and manage risks to patients for infection prevention and control (IPC) and the management of medical emergencies.
- The practice had safeguarding processes and staff understood their responsibilities for safeguarding adults and children.
- Patients were given information and time to make informed decisions about their treatment and staff ensured patients gave their consent before treatment began.
- The content of dental care records was brief but included the essential information that would be expected to be recorded during a patient assessment.
- Staff had received training appropriate to their roles and were supported in their continued professional development (CPD).
- Patients were able to make routine and emergency appointments when needed. There were clear instructions for patients regarding out of hours care.
- Staff recruitment procedures did not ensure that all of the required checks for new staff were completed.
- Staff appraisals were not carried out.
- There were deficiencies in the management of medicines dispensed and administered by the practice.
- The practice was not consistently recording the quality of dental X-rays in accordance with IRMER 2000.
We identified regulations that were not being met and the provider must:
- Establish an effective system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, staff and visitors. Specifically relating to policies and procedures for the safe use of dental sharps to reflect the requirements of the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 and the EU Directive on the safer use of sharps which came into force in 2013.
- Ensure the application of recruitment procedures which fully reflect the requirements of Regulation 19(3) and Schedule 3 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014.
- Introduce an effective programme of staff appraisals.
- Establish a system of stock control, secure storage and dispensing protocols for medicines supplied directly by the practice. This includes antibiotic and analgesic medicines.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Consider recording more detail in the dental care records of the care and treatment provided to patients.
- Give due regard to the IRMER 2000 guidelines so that a record of the quality assessment score for each dental X-ray is made on every occasion.