Kinnersley House

We carried out this announced inspection on 28 September 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.

As part of this inspection we asked;

• Is it safe?

• Is it effective?

• 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 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 well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Kinnersley House is in Needham Market, Suffolk and provides NHS and private dental care and treatment for adults and children.

Due to the age and limits of the building the practice is unable to provide access for people who use wheelchairs. Car parking spaces, including dedicated parking for people with disabilities, are available in car parks near the practice.

The dental team includes five dentists, six dental nurses, one dental hygiene therapist, one orthodontic therapist, the practice manager, one receptionist and a cleaner. The practice has four treatment rooms.

The practice is owned by a partnership and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Kinnersley House is the senior partner.

During the inspection we spoke with three dentists, three dental nurses, the dental hygiene therapist, and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday from 9am to 5pm.

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had some infection control procedures which reflected published guidance. However, there were no documented infection control leads, and gaps in infection control audits and training were evidenced.
• Staff knew how to deal with medical emergencies. Not all appropriate medicines and life-saving equipment were available. The practice took immediate action to rectify this.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Staff recruitment procedures reflected current legislation. However, these procedures were not always followed as details of disclosure and barring checks and photographic identification for three members of staff were missing.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Effective leadership or a culture of continuous improvement was not evidenced. Staff appraisals were not undertaken. Information regarding staff lead roles was conflicting. We were assured these would be implemented following our inspection.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Staff worked as a team.
• The provider dealt with complaints positively and efficiently.
• The provider demonstrated they were taking responsive action to the shortfalls we identified following our visit.

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/s the provider was/is not meeting are at the end of this report.

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

• Implement an effective system of checks of medical emergency equipment and medicines to ensure full compliance with the Resuscitation Council (UK) and the General Dental Council guidance.