Updated 4 August 2023
We carried out this announced comprehensive inspection on 28 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 and well-maintained.
- The practice had infection control procedures which did not fully reflect published guidance.
- Staff knew how to deal with medical emergencies.
- Improvements could be made to ensure all appropriate medicines and life-saving equipment were available and reflected current guidelines.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- Improvements could be made to ensure substances hazardous to health were appropriately risk assessed.
- 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.
- There was effective leadership and a culture of continuous improvement; systems to ensure audits were effective could be improved.
- Staff felt involved, 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 practice had information governance arrangements.
Background
Eden Dental is in Edenthorpe, Doncaster and provides private dental care and treatment for mostly adults and a small number of children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the practice and nearby on local roads. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 1 dentist and 1 dental nurse. The practice has 1 treatment room.
During the inspection we spoke with the dentist and the dental nurse.
We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open: Monday 12pm – 6pm, Tuesday 9am – 8pm, alternate Wednesday and Friday 9am – 3pm and Thursday 9am – 6pm.
The practice had taken steps to improve environmental sustainability. For example, reducing paper and electrical use where possible.
There were areas where the provider could make improvements. They should:
- Review the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
- Review current systems to ensure the availability of emergency medicines and equipment in the practice to manage medical emergencies taking into account the guidelines issued by the guidelines issued by the British National Formulary, Resuscitation Council (UK) and the General Dental Council.
- Improve the practice's processes for the control of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken.
- Take action to ensure audits of radiography, infection prevention and control and antimicrobial prescribing are undertaken at regular intervals in line with guidance 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.