Elland Practice Limited

We carried out this unannounced inspection on 4 December 2020 with a further announced inspection visit on 16 December 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.

As part of this inspection we asked:

• Is it safe?

• 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 not providing safe care in accordance with the relevant regulations.

Are services well-led?

We found this practice was not providing well-led care in accordance with the relevant regulations.

Background

Elland Practice Limited is in Elland, West Yorkshire and provides NHS and 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. On street parking is available near the practice.

The dental team includes one dentist, a practice manager, three dental nurses and a receptionist. The practice has two treatment rooms, a third treatment room is under development.

The practice is owned by a company and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Elland Practice Limited is the principal dentist.

During the inspection we spoke with the principal dentist, two dental nurses and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday to Friday 9am to 12:30pm and 1:30pm to 5pm.

Our key findings were:

• Clinical areas appeared to be visibly clean and well-maintained. Instrument decontamination procedures reflected published guidance. Environmental cleaning and the monitoring of this needed to be improved.
• The provider had implemented standard operating procedures in line with national guidance on COVID-19.
• Staff knew how to deal with emergencies. Improvements were needed to the management and availability of life-saving equipment and medicines available.
• The provider did not have effective systems to help them identify and manage risk to patients and staff. In particular, fire and electrical safety, radiography, Legionella, hazardous substances and incident reporting.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• Staff recruitment procedures did not reflect current legislation.
• The provider had not established effective leadership and systems of governance.
• 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. Arrangements for closed-circuit television (CCTV) were not in line with legislation.

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 is not meeting are at the end of this report.

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

• Take action to ensure that clinicians take into account guidance provided by the Faculty of General Dental Practitioners when completing dental care records.

• Improve the security of NHS prescription pads in the practice.

• Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.