Updated 22 October 2021
We carried out this announced focussed inspection on 11 October 2021 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 three 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:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
The Limes Dental Practice is in Appleby and provides private and NHS dental treatment for adults and children.
The service is located on the ground floor and accessible for people who use wheelchairs and those with pushchairs. Car parking is available outside the practice and local transport links are nearby.
The dental team includes four dentists, one dental hygienist, five dental nurses, three receptionists and one practice manager. The practice has three treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with one dentist, two dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday 9am -6pm
Tuesday to Thursday from 9am to 5pm
Friday 9am-2:30pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance. Improvements could be made to the testing of decontamination equipment by following the manufactures instructions.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems in place to help them manage risk to patients and staff. Improvements could be made to the fire risk assessment and the fire detection system checks.
- 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.
- 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 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 had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to review the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Improve the practice's systems for checking and monitoring decontamination equipment taking into account manufacturer’s instructions in completing the required validation test for the ultrasonic bath.
- Improve the monitoring of NHS prescription pads in the practice and ensure there are systems in place to track their use.