Rotherholme Dental Practice

We carried out this announced inspection on 1 December 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 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.

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 form the framework for the areas we look at during the inspection.

Our findings were:

• The dental clinic was visibly clean and well-maintained.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not always available in accordance with resuscitation council UK guidance.
• The provider had systems to help them manage risk to patients and staff. These were not always effective as fire and legionella risk management required improvement.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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 has 1 practice and this report is about Rotherholme Dental Practice.

Rotherholme Dental Practice is in Ashby de la Zouch in Leicestershire and provides NHS and private dental care and treatment for adults and children.

The practice is accessed via a small flight of steps meaning it is not accessible for people who use wheelchairs and those with pushchairs. Arrangements are in place to refer patients to nearby accessible services. Car parking spaces, including dedicated parking for people with disabilities, are available at the practice.

The dental team includes 3 dentists, 4 dental nurses, and 1 receptionist. The practice has 2 treatment rooms.

During the inspection we spoke with 1 dentist, 3 dental nurses, and 1 receptionist. We looked at practice policies and procedures and other records about how the service is managed.

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

• Take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ In particular, ensure remedial action recommended in the legionella risk assessment is taken and ensure water temperature checks of sentinel outlets are recorded accurately and action taken when required.

• Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective. In particular ensure the effective operation and visibility of means of escape.