15/03/2022
During an inspection looking at part of the service
We carried out this announced focused inspection on 15 March 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.
- Except for minor adjustments needed, the practice infection control procedures 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.
- Systems for reviewing and investigating when things went wrong could be improved.
- 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.
- The dental clinic had information governance arrangements.
Background
Doncaster Dental Centre is in Doncaster town centre and provides NHS and private dental care and treatment for adults and children.
The practice is in a pedestrian area of town and is situated on the first floor of a shopping complex. Access to the practice is via one flight of stairs; the practice information leaflet informs patients of this. People who may struggle with the stairs are directed to more accessible locations. There are several car parks located close to the practice.
The dental team includes six dentists, seven dental nurses, three of whom are trainee dental nurses and three receptionists. The team is supported by a practice manager and a deputy manager. The practice has five treatment rooms.
During the inspection we spoke with two dentists, two dental nurses, and the practice managers. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday from 9am to 5:30pm
Friday from 9am to3pm.
There were areas where the provider could make improvements.
- Review the practice’s infection control procedures and protocols 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: relating to instrument transportation, the decontamination flow process and equipment validation.
- Review the system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.