Updated 11 July 2022
We carried out this announced focused inspection on 28 June 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 was 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 most life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff. However, we found recommendations identified in the legionella risk assessment had not implemented.
- 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 and these were followed most of the time.
- 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 three practices and this report is about Pontesbury Dental.
Pontesbury Dental is in Pontesbury and provides NHS and private dental 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 practice has made some adjustments to support patients with additional needs.
The dental team includes three dentists, six dental nurses (three are trainees), two dental hygienists, three receptionists, one clinical director, one operations director and one practice manager. The practice has three treatment rooms.
During the inspection we spoke with three dentists, one dental nurse, two receptionists 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, Tuesday and Wednesday from 8.30am to 6pm.
Thursday from 8.30am to 8pm.
Friday from 8.30am to 4pm.
Saturday by arrangement.
There were areas where the provider could make improvements. They should:
- Ensure the practice follows their own recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
- Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to implement any recommendations in the practice's Legionella risk assessment.
- The practice should also ensure that audits have documented learning points and the resulting improvements can be demonstrated.