Updated 18 March 2022
We carried out this announced, focused inspection on 8 February 2022 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 provider 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 adviser.
To get to the heart of patients’ experiences of care and treatment, we asked the following questions:
• Is it safe?
• Is it effective?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Some dental instruments, prepared and ready for use, had exceeded their use by date. Some were visibly tarnished. The provider disposed of these immediately.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available, with the exception of some items which were missing from the kit. These were ordered on the day of our inspection.
- Medicines were not always stored appropriately.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation. We found that not all procedures were followed. Appropriate pre employment checks were not always carried out.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
Background
Sherwood House Dental Practice is in Loughborough, Leicestershire and provides NHS and private general dental care and treatment for adults and children.
There is level access to the practice for people with restricted mobility and those with pushchairs. Dedicated disabled parking is not available, although patients can book a space in a small car park at the rear of the practice.
The dental team includes four dentists, a foundation dentist, eight dental nurses (of whom three are trainees), two hygienists and one receptionist. Practice management duties are shared between nursing staff. The practice has eight treatment rooms, two of which are not in use.
During the inspection we spoke with three dentists, four dental nurses and the hygienist. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday from 8.30am to 5.30pm.
Friday from 8.30am to 4.30pm.
There were areas where the provider could make improvements. They should:
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.
Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. Specifically, to ensure that references are sought for all new staff.
Implement an effective system for identifying, disposing and replenishing of out-of-date stock.