Rothley Lodge Dental Surgery

We carried out this announced focused inspection on 30 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 life-saving equipment were available.
• Safeguarding processes were in place 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 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.
• Staff and patients were asked for feedback about the services provided.
• The dental clinic had information governance arrangements.
• The provider had staff recruitment procedures which reflected current legislation. However, improvements were needed to ensure important checks were carried out at the time of recruitment.
• The practice had some systems to help them manage risk to patients and staff. However, improvements could be made in relation to the ongoing fire monitoring protocols.
• Improvements were needed to ensure all equipment was serviced and maintained in accordance with manufacturer’s guidelines.

Background

Rothley Lodge Dental Surgery is in Staines-upon-Thames 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. The practice is located close to local transport routes and car parking spaces are available at the practice and in surrounding roads. The practice has made some adjustments to support patients with additional needs, for example the availability of ramps to access the surgery.

The dental team includes 11 dentists, including three specialists/special interest dentists, four dental nurses, four trainee dental nurses, five dental hygienists, four receptionists and a practice manager. The practice has seven treatment rooms.

During the inspection we spoke with three dentists, two dental nurses, one trainee dental nurse 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 to Thursday from 8.00 am to 6.00 pm

Friday from 8.00 am to 4.30 pm

Saturday by Appointment only

The practice had taken steps to improve environmental sustainability. They have introduced recyclable and more sustainable materials for example, paper cups for patients and offer bamboo based dental brushes instead of plastic alternatives. Re-usable equipment is used instead of single-use plastic items wherever possible and additional protocols are in place to ensure the safety of these items. They have a recycling service available to patients for plastic toothpaste tubes and retainers. The practice also has a designated sustainability lead who supports the team by continually looking into new ways to improve sustainability.

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

• Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, ensuring all suction motors, the intra-oral X-ray units and the emergency lighting are serviced and maintained according to manufacturer’s guidance. In addition, ensure assessments of the gas safety and fixed-wiring are undertaken at the required intervals.
• Improve the practice's recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. Also take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
• Take action to ensure, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.