Cavendish Dental Practice

We carried out this announced comprehensive inspection on 20 September 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 generally clean. We identified some areas that required repair and update to ensure they could be well-maintained.
• The practice had infection control procedures which reflected published guidance. We found these were not always implemented effectively.
• Staff knew how to deal with medical emergencies. Systems to ensure that appropriate medicines and life-saving equipment were available required improvement.
• Practice systems to manage risks for patients, staff, equipment and the premises were not effective, specifically for fire safety and legionella management.
• Safeguarding processes were in place, embedded into practice procedures 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.
• 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

Cavendish Dental Practice is in Derby and provides NHS and 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, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 8 dentists, 1 foundation dentist 7 dental nurses, 4 trainee dental nurses, 1 dental therapist, 1 practice manager and 2 receptionists. The practice has 7 treatment rooms.

During the inspection we spoke with 2 dentists, the foundation dentist, 3 dental nurses, 2 receptionists and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday from 8.45am to 7pm

Tuesday from 8.45am to 5.30pm

Wednesday from 9am to 4pm

Thursday from 9am to 5.30pm

Friday from 9am to 5pm

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 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’ In particular, that recommended processes are followed for manual cleaning of instruments and all work surfaces and furniture in treatment rooms are in a good state of repair and able to be cleaned satisfactorily.

• Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.

• Take action to ensure audits of radiography and infection prevention and control are undertaken at regular intervals 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.