Updated 15 August 2023
We carried out this announced comprehensive inspection on 19 July 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 reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- 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.
- Improvements were needed to the systems to help the provider manage risk to staff and patients.
- The practice had staff recruitment procedures which reflected current legislation; however, staff records were incomplete.
Background
W M Rosten Dental Surgery is known as TW13Dental and is in the London Borough of Richmond-upon-Thames 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 are available at the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 4 dentists, 1 foundation training dentist, 2 qualified dental nurses, 2 trainee dental nurses, 1 dental hygienist, 1 practice manager and 1 receptionist. The practice has 3 treatment rooms.
During the inspection we spoke with 1 dentist, the qualified dental nurses, the trainee dental nurses, the dental hygienist and the practice manager. The principal dentist was not present but was contacted remotely. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Friday from 9am to 5pm
Saturday from 8.30am to 2pm
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.
- Take action to ensure the practice stores records relating to people employed and the management of regulated activities in compliance with legislation and take into account current guidance.
- Improve and develop staff awareness of autism and learning disabilities and ensure all staff receive appropriate training in this.