Mr & Mrs S Odai Dental Surgery - Stainforth

We carried out this announced comprehensive inspection on 6 March 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.
• Infection prevention and control systems were not carried out in accordance with published guidance.
• Emergency medicines and life-saving equipment were available but the system to monitor this was not effective.
• Improvement was needed to risk management systems in respect of fire, sharps, legionella, and lone working.
• Safeguarding processes were in place. A review of policy and protocols with staff would be beneficial.
• The practice had staff recruitment procedures which reflected current legislation.
• Professional indemnity and Hepatitis B immunity records were not available for all staff; the missing records were sent after the inspection.
• Improvement was needed in respect to referral and prescription management.
• 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.
• Systems to ensure staff awareness of consent to care and treatment and requirements of the Mental Capacity Act 2005 should be improved.
• Quality assurance systems should be improved.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• The practice had information governance arrangements.
• Arrangements to ensure good governance and leadership are sustained in the longer term were not operating effectively.

Background

Mr and Mrs Odai Dental Practice is in Doncaster and provides mainly NHS and a small amount of 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 are available near the practice on local roads. The practice has made reasonable adjustments to support patients with access requirements, including ramp access and two ground floor treatments rooms.

The dental team includes 2 dentists, 3 dental nurses and 1 receptionist. The practice has 2 treatment rooms.

During the inspection we spoke with 1 dentist and 2 dental nurses. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday, Tuesday and Wednesday 9am – 5:30pm

Thursday 9am – 7pm

Friday 9am – 5pm

Saturday 9am – 1pm

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 regulation the provider was not meeting are at the end of this report.

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

• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment, for example, grading of X-rays and quality assurance.
• Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.
• Improve and develop the practice's policies and procedures for obtaining patient consent to care and treatment to ensure they are in compliance with legislation, take into account relevant guidance, and staff follow them.
• Improve and develop staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.