Updated 19 April 2023
We carried out this announced comprehensive inspection on 28 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, tidy and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available. Some masks and airways had passed their expiry dates, these were replaced immediately.
- The practice had systems to manage risks for patients, staff, equipment and the premises. Minor shortfalls were identified in relation to managing risks associated with legionella and COSHH.
- 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. Procedures should be reviewed to ensure relevant information is obtained for agency staff.
- 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
Bolton Street Dental Practice is in Ramsbottom 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 1 dentist, 4 dental nurses who also cover reception and 1 dental therapist. The practice has 2 treatment rooms.
During the inspection we spoke with the dentist, 3 dental nurses and the dental therapist. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Friday 9am to 1pm and 1.45pm to 5.30pm.
There were areas where the provider could make improvements. They should:
- Implement an effective recruitment procedure to ensure evidence is sought that appropriate checks are completed prior to agency staff working at the practice.
- Improve the practice's processes for the control and storage 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 the practice's Legionella risk assessment is up to date, 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.’