Updated 19 July 2021
We carried out this announced focused inspection on 22 June 2021 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 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.
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Churchdown Dental Surgery is in Churchdown 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 people with disabilities, are available near the practice.
The dental team includes three dentists, three dental nurses and five receptionists. The practice has four treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with two dentists, two dental nurses a receptionist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
- Monday to Thursday 8am to 6pm
- Friday 8am to 4.30pm
- One Saturday per month 8am to 1pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not fully available or checked according to guidance.
- The provider had systems to help them manage risk to patients and staff. Some risk assessments were based on out of date information, and not all hazardous materials, for example gas storage adjacent to the practice, were risk assessed.
- The provider had some policies which were based on out of date legislation.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and 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 a need to establish a culture of continuous improvement in relation to infection prevention control and antimicrobial audits.
- 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 had information governance arrangements.
There were areas where the provider could make improvements. They should:
- 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.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- Take action to ensure audits of infection prevention and control and the prescribing of antibiotic medicines are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities, in particular that policies are based on up to date legislation.