The Holbeck Dental Practice

We carried out this announced focused inspection on 23 February 2022 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 usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were 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:

• The dental clinic appeared to be visibly clean and well-maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk to patients and staff.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Improvements should be made to the Radiation Protection file to ensure it complies with current legislation and guidelines.
• The practice had staff recruitment procedures which reflected current legislation.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Patients were treated with dignity and respect and staff 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.
• There was effective leadership and a culture of continuous improvement.
• Staff felt involved and supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• Complaints were dealt with positively and efficiently.
• The dental clinic had information governance arrangements.

Background

The provider only has one practice and this report is about Holbeck Dental Practice.

The practice is in the south west part of Leeds and provides mostly NHS dental care and treatment (95%) to adults and children.

There is are two small steps into the practice, which is accessible for people who use wheelchairs and those with pushchairs despite the steps. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice. The practice has made some adjustments to support patients with additional needs. For example, there is a hearing loop for patients who use hearing aids, and grab rails by the steps outside.

The dental team includes one dentist and two dental nurses, including one trainee dental nurse. The practice has one treatment room.

During the inspection we spoke with the dentist and the dental nurses. 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.

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

• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

• Take action to ensure audits of antimicrobial prescribing are undertaken at regular intervals to improve patient safety. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.