Caldecott Dental Practice

We carried out this announced comprehensive inspection on 1 June 2023 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 advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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 appeared clean.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The practice systems to help them manage risk to patients and staff were not robust or effective. Specifically, fire safety and legionella management.
• 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.
• Clinical staff provided patients’ care and treatment in line with current guidelines.
• Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system worked efficiently to respond to patients’ needs.
• The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
• Effective leadership and a culture of continuous improvement required improvement.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided. There was scope for improvement in responding to online feedback and ensuring audits accurately reflected findings.
• Overall governance systems in the practice required strengthening.

Background

The provider has 1 practice, and this report is about Caldecott Dental practice.

Caldecott Dental practice is in Rugby and provides NHS and private dental care and treatment for adults and children.

There is step free 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 reasonable adjustments to support patients with access requirements.

The dental team includes 4 dentists, 4 qualified dental nurses, 1 trainee dental nurse, 1 dental hygienist, 1 dental therapist, 1 practice manager and 1 receptionist. The practice has 4 treatment rooms.

During the inspection we spoke with 2 dentists, 1 dental nurse, 1 trainee dental nurse, 1 dental therapist and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Friday from 9am to 5pm.

Saturdays by appointment only.

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulations the provider was not meeting are at the end of this report.

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

• Implement an effective system for identifying, disposing, and replenishing of out-of-date stock.
• Implement a system to ensure patient referrals to other dental or health care professionals are actively monitored to ensure they are received in a timely manner and not lost.