Updated 3 November 2021
We carried out this announced focussed inspection on 19 October 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 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.
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
Bailiff Bridge Dental Practice is near Brighouse and provides and NHS dental treatment for adults and children.
Whilst wheelchair access is not available, for patients with some mobility needs there is a treatment room based on the ground floor. Car parking is available outside the practice and local transport links are nearby.
The dental team includes three dentists, one dental hygienist, seven dental nurse/receptionists and a practice manager.
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 Bailiff Bridge Dental Practice is the principal dentist.
During the inspection we spoke with one dentist, one dental hygienist, two dental nurses 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, Wednesday 8:30am - 6pm
Thursday and Friday 8:30am - 6.30pm.
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had implemented standard operating procedures in line with national guidance on COVID-19.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff.
- Improvements could be made to the testing of decontamination equipment by following the manufactures instructions.
- 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 provided preventive care and supported patients to ensure better oral health.
- Staff felt involved and supported and worked as a team.
- The provider had information governance arrangements.
- The provider’s recruitment records were incomplete and did not meet with current legislation and the provider did not have oversight of staff training.
There were areas where the provider could make improvements. They should
- Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
- Improve the practice's systems for checking and monitoring decontamination equipment taking into account manufacturer’s instructions in completing the required tests.
- Improve the monitoring of referrals to dental or health care professionals to ensure they are followed up and not lost.
- Improve awareness and understanding of sepsis within the staff team.