Berkeley Dental Practice

We carried out this announced comprehensive inspection on 17 May 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. However, not all of the life-saving equipment was available as per national guidelines. Following the inspection, the provider took timely action to rectify this.
• 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 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.
• Improvements were needed to the systems to help the provider manage risk to patients and staff.
• The practice did not have staff recruitment procedures which reflected current legislation.
• Improvements were needed to the Information Governance policy to take account the General Data Protection Regulation (GDPR) 2018 requirements.

Background

Berkeley Dental Practice is in the London Borough of Hounslow and provides NHS and or 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 at the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 4 dentists, 1 qualified dental nurse, 2 trainee dental nurses, 2 dental hygienists, 1 practice manager and 1 receptionist. The practice has 2 treatment rooms.

During the inspection we spoke with the principal dentist, an associate dentist, the dental nurse, 1 receptionist 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 to Friday from 9.30am to 5.30pm

Saturday from 9.30am to 1pm

We identified regulations the provider was not complying with. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure specified information is available regarding each person employed.

Full details of the regulations the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

• Implement an effective system for monitoring and recording the fridge temperature to ensure that medicines and dental care products are being stored in line with the manufacturer’s guidance.
• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment.

Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and continuing professional development.