Updated 23 January 2023
We carried out this announced comprehensive inspection on 12 January 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. Improvements were needed to ensure all appropriate medicines and life-saving equipment were available as recommended.
- 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.
- 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 could be made to the systems for managing risks, in particular in relation to Legionella and fire safety.
Background
Windermere Dental Practice is in Windermere in Cumbria and provides private dental care and treatment for adults and children.
There is ramped access to the practice for people who use wheelchairs and those with pushchairs. The practice is located close to local transport routes and car parking spaces are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 1 dentist, 2 dental nurses, 1 dental therapist and a practice manager. The practice has 2 treatment rooms.
During the inspection we spoke with the dentist, both dental nurses, the dental therapist 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 and Tuesday from 8.30am to 6pm
Wednesday to Friday from 8.30am to 4.30pm
There were areas where the provider could make improvements. They should:
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Improve the ongoing management of Legionella, 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.’