Updated 7 June 2019
We carried out this announced inspection on 28 May 2019 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 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 that this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this practice was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this practice was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this practice was providing well-led care in accordance with the relevant regulations.
Background
The Compass Clinic- Holt provides NHS private treatment to approximately 5,500 patients of all ages. The practice is one of two owned by the company and has a sister practice in Wells-next- to the- Sea. The practice is based within the grounds of a local community hospital and rents the premises from the local health service trust.
There is level access for people who use wheelchairs and those with pushchairs. There is parking close by for people with mobility problems.
The dental team include two dentists, a part-time hygienist, three dental nurses, a practice manager and receptionist. There are three treatment rooms. The practice opens on Monday to Friday, from 9 am to 5pm.
As a condition of registration, the practice must have a person registered with the Care Quality Commission 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 is the company’s chief executive officer, who also acts as the practice manager.
On the day of inspection, we collected eight CQC comment cards filled in by patients and spoke with two other patients. We spoke with both dentists, the dental hygienist, the practice manager, and two dental nurses.
We looked at practice policies and procedures and other records about how the service is managed.
Our key findings were:
- The practice appeared clean and well maintained and infection control procedures reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- The practice had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice took patients’ complaints seriously and responded to them appropriately to improve the quality of care.
- Patients received their care and treatment from well supported staff, who enjoyed their work.
- The provider asked staff and patients for feedback about the services they provided.
There were areas where the provider could make improvements and should:
- Review practice's recruitment procedures to ensure that appropriate background checks are completed prior to staff commencing employment at the practice.
- Review the practice’s protocols for the use of dental dams for root canal treatment taking into account guidelines issued by the British Endodontic Society.
- Review the practice's protocols for ensuring that dental clinicians follow national best practice guidance in relation to antibiotic prescribing and managing gum disease.
- Review staff awareness of the requirements of the Mental Capacity Act 2005 and Gillick competence guidelines to ensure they are aware of their responsibilities when treating younger patients and those that might not be able to understand their treatment.