Archived: Church Street Dental Practice

We carried out this announced comprehensive inspection on 14 November 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. Appropriate medicines and life-saving equipment were available.
• There were systems in place to ensure most equipment was safe to use. The practice did not have effective systems to manage risks for patients, staff and the premises.
• Safeguarding processes were in place. Improvements were needed to ensure all members of staff completed safeguarding training at a level appropriate to their role.
• The practice did not have suitable recruitment procedures to comply with 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.
• Improvements were needed to ensure 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.

Background

Church Street Dental Practice is in the London Borough of Enfield and provides NHS and 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 near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 1 principal dentist, 7 dentists, 1 foundation dentist, 4 dental nurses, 4 trainee dental nurses, 6 receptionists and 1 administrator. The practice has 6 treatment rooms.

During the inspection we spoke with the principal dentist, 1 qualified nurse, 1 trainee dental nurse and 2 receptionists. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open:

Monday to Thursday from 8am to 5pm

Friday from 8am to 3pm.

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

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are 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:

• Take action to ensure audits of record keeping and antimicrobial prescribing are undertaken at regular intervals to improve the quality of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
• 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. In particular, ensure that elector-mechanical servicing of the radiation equipment is carried out in line with the manufacturer`s guidance or annually and rectangular collimators are used with the intraoral X-ray units.