Archived: Mr I T Burrell Dental Surgery

We carried out this announced inspection on 23 August 2017 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 CQC inspector who was supported by a specialist dental adviser.

We told the NHS England area team and Healthwatch that we were inspecting the practice. They did not provide any information of concern.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five 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:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Mr I T Burrell Dental Surgery is in Grimsby and provides NHS treatment to patients of all ages.

There is level access for people who use wheelchairs and pushchairs. Car parking spaces are available near the practice.

The dental team includes four dentists, a dental hygienist, seven dental nurses, a decontamination assistant, three receptionists and a practice manager (who is also a qualified dental nurse). The practice has six treatment rooms.

The practice is owned by an individual who is the practice owner. 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.

On the day of inspection we collected 18 CQC comment cards filled in by patients. This information gave us a positive view of the practice.

During the inspection we spoke with two dentists, one dental nurse, the decontamination lead, one receptionist, the practice manager and the registered provider. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Thursday from 9:00am to 5:30pm

Friday from 9:00am to 3:00pm

Our key findings were:

• The practice was clean and well maintained.
• Infection control procedures reflected published guidance. The layout of the decontamination room did not reflect current guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available. The process for checking emergency medicines and equipment could be improved.
• The practice had limited systems in place to manage risk. These included risks associated with fire and sharps.
• The practice did not have effective recruitment procedures.
• 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.
• The appointment system met patients’ needs.
• Governance arrangements were not in place to support the smooth running of the service.
• The practice asked patients for feedback about the services they provided.

We identified regulations that were not being met and the provider 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 and should:

• Review the process for checking emergency medicines and equipment giving due regard to guidelines issued by the Resuscitation Council (UK).
• Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.
• Review the layout of the decontamination room giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices.
• Review the availability of an interpreter service for patients who do not speak English as their first language.