We carried out this announced comprehensive inspection on 10 January 2013 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 adviser.
To get to the heart of patients’ experiences of care and treatment, we ask five key questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive?
- Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The dental practice was visibly clean.
- Patients were treated with dignity and respect and staff took care to protect their personal information.
- Staff knew how to deal with medical emergencies.
- The provider did not operate effective systems to help them manage risk to patients and staff. Improvements were needed to the management of fire safety, infection control, COSHH and legionella.
- Staff felt involved and supported and worked as a team.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Staff recruitment procedures were not operated effectively.
- The appointment system took account of patients’ needs.
- Staff provided preventive care and supported patients to ensure better oral health.
- Staff training was not monitored effectively.
- Complaints were dealt with positively and efficiently.
Background
Bespoke Smile Marlow is in Marlow and provides private dental care and treatment for adults and children.
The practice is based on the first floor. New patients are advised of this when they contact the practice.
Car parking spaces, including dedicated parking for disabled people, are available near the practice.
The dental team includes 4 dentists, 1 dental specialist, 4 dental nurses, 1 student dental nurse, 1 dental therapist, 1 treatment coordinator, a receptionist and a business director.
The practice has 2 treatment rooms and a consultation room.
During the inspection we spoke with 2 dentists, 2 dental nurses, an administrator and a receptionist. We also spoke to one of the practice partners by teleconference.
We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
- Monday 9am to 5pm
- Tuesday 8am to 5pm
- Wednesday 9am to 5pm
- Thursday 9am to 5pm
- Friday 9am to 5pm
- Saturday by appointment
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.
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed and specific information is available regarding each person 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 a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
Where evidence is sent that shows the relevant issues have been acted on, we have stated this in our report but we cannot say that the practice is compliant for that key question as this would not be an accurate reflection of what was found on the day of our inspection.