Loughborough University Dental Practice

Updated 7 January 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The inspection took place on 29 October 2015 and was conducted by a CQC inspector and a specialist dental advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Prior to the inspection we asked the practice to send us some information which we reviewed. This included the complaints they had received in the last 12 months, their latest statement of purpose, the details of their staff members, their qualifications and proof of registration with their professional bodies.

We also reviewed the information we held about the practice and found there were no areas of concern.

During the inspection we spoke with a number of staff working on the day. We reviewed policies, procedures and other documents. We reviewed comment cards that we had left prior to the inspection, for patients to complete, about the services provided at the practice.

Updated 7 January 2016

We carried out an announced comprehensive inspection on 29 October 2015 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

The practice is based on the campus of Loughborough University. It has been located in its present site since it started in 1994 and consists of three treatment rooms, a central decontamination room, and a small patient waiting room at reception. The practice has pay and display parking on the University campus grounds where disabled parking is also available. The practice is a single storey building and there is easy access to the treatment rooms for patients using wheelchairs and those with limited mobility

There are three dentists and five dental nurses who also cover reception duties. The provider who is the principal dentist is also the practice manager. The current owner took over in 1994 and at the time of our inspection was going through the process of selling the practice to the two associate dentists in the practice.

The practice provides both NHS and private dental treatment to both adults and to children. The practice is open Monday to Thursday from 9.00am to 5.30pm and Friday 8.00am to 1.30pm.

The provider is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

We received feedback from 49 patients about the services provided. All of the feedback reflected positive comments about the staff and the services provided. Patients commented that the practice was clean and tidy; they found the staff offered a friendly service and were helpful, kind and caring. They found the practice to be clean and tidy. They said explanations were clear and that they were always informed of what was happening which made the dental experience as comfortable as possible.

The practice was providing care which was safe, effective, caring, responsive and well-led in accordance with the relevant regulations.

Our key findings were:

• Staff had received safeguarding training and knew the processes to follow to raise any concerns.
• There were sufficient numbers of suitably qualified staff to meet the needs of patients.
• Infection control procedures were in place and staff had access to personal protective equipment.
• Patients’ care and treatment was planned and delivered in line with evidence based guidelines and current legislation.
• Patients received clear explanations about their proposed treatment, costs, benefits and risks and were involved in making decisions about them.
• Patients were treated with dignity and respect and confidentiality was maintained.
• The appointment system met the needs of patients and waiting times were kept to a minimum.
• There was an effective complaints system.
• The practice was well-led and staff felt involved and worked as a team.
• Staff had been trained to deal with medical emergencies and appropriate medicines and life-saving equipment were readily available and accessible.
• Governance systems were effective although policies and procedures had not been reviewed for up to two years.
• The practice staff and manager were unable to locate portable suction.
• The practice did not record and analyse significant events.

There were areas where the provider could make improvements and should:

• Review availability of equipment to manage medical emergencies giving due regard to guidelines issued by the Resuscitation Council (UK), and the General Dental Council (GDC) standards for the dental team.
• Infection control process to be laminated and displayed for all staff to have access to and be practice specific.
• Review the cleaning and sterilising process in relation to published guidance (HTM 01-05).
• Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society.
• Review the practice’s sharps procedures giving due regard to the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Review the practice protocols for the servicing and maintenance of equipment. Ensure a new contract for the servicing of the compressor is in place.