Maidenhead Orthodontic Centre

We carried out this announced inspection on 13 September 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 asked the following three questions:

• Is it safe?

• Is it effective?

• Is it well-led?

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

Background

Maidenhead Orthodontic Centre is in Maidenhead, Berkshire, and provides NHS and private orthodontic care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice.

The dental team includes three orthodontists, one of whom is also the practice manager, three orthodontic nurses, a receptionist, and a trainee orthodontic therapist. The practice has two treatment rooms.

The practice is owned by a company 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 Maidenhead Orthodontic Centre is an orthodontist and practice director.

On the day of inspection, spoke with 3 patients, and all staff members except an orthodontist and an orthodontic nurse. 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 5.30pm.

Our key findings were:

• The practice appeared to be visibly clean.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Staff treated patients with dignity and respect
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• Staff felt involved and supported and worked as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had information governance arrangements.
• The provider had staff recruitment procedures which reflected current legislation for all but one member of staff.
• Close circuit television recording (CCTV) arrangements did not suitably protect people’s privacy and personal information.
• The provider had ineffective systems to help them manage risk to patients and staff.
• The provider demonstrated ineffective leadership in areas and did not demonstrate a culture of continuous improvement.
• The provider had infection control procedures, but these did not reflect published guidance in some areas.
• Appropriate medicines and life-saving equipment were available, but one had passed its expiry date.
• Staff knew how to deal with emergencies, but we were not assured that all staff were suitably trained and confident in using firefighting equipment.

We identified regulations the provider was not complying with. Full details of the regulations the provider is 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 non-electronic patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
• Implement practice protocols and procedures to ensure staff are up to date with training in relation to sepsis awareness.