Archived: Mexborough Dental Surgery

Updated 20 April 2020

We carried out this announced inspection on 2 March 2020 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 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 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 caring?

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

Are services responsive?

We found this practice was providing responsive 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

Mexborough Dental Surgery is in Mexborough, South Yorkshire and provides mainly NHS and a small amount of private dental care and treatment for adults and children.

There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the rear of the practice and on local roads.

The dental team includes two dentists, one is the principal dentist, three dental nurses, two dental hygiene therapists and a practice manager. The practice has two 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.

On the day of inspection, we collected 13 CQC comment cards filled in by patients. All comments reflected positively on the service provided.

During the inspection we spoke with the principal 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 2pm to 5:30pm

Tuesday and Thursday 9am to 1pm

Wednesday 2pm to 5:30pm

Friday 9am to 12:30pm

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures. These could be improved to ensure they fully reflected published guidance.
• Staff knew how to deal with emergencies. Improvements could be made to ensure all appropriate medicines and life-saving equipment were available and the checks were in line with guidance.
• The provider had systems to help them manage risk to patients and staff.
• The system to ensure staff had adequate immunity for vaccine preventable infectious diseases required review.
• 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.
• 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.
• The processes in place to ensure continuous improvement required review.
• 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.

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

• Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular: equipment validation checks and instrument cleaning and transportation processes.

• Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.

• Implement an effective system of checks of medical emergency equipment and medicines taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.

• Take action to ensure audits of radiography and dental patient care records are clinician specific and that infection prevention audits accurately reflect processes in place.