Archived: Compass Clinic - Wells-next-the-Sea

We carried out this announced inspection on 23 May 2018 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. We had also received a number of complaints about the practice. 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 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 not providing responsive 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

The Compass Clinic provides both NHS and private treatment to patients of all ages. The practice opens on Monday to Friday, from 9 am to 5pm. The practice is one of two owned by the company, and is based in the local community hospital and shares many of its facilities.

There is level access for people who use wheelchairs and those with pushchairs.

The permanent dental team includes one dentist, one dental nurse and one reception staff. Due to recruitment difficulties, locum staff are also employed. A hygienist works two afternoons a month. The practice has two treatment rooms.

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 seven CQC comment cards filled in by patients and spoke with two other patients.

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

Our key findings were:

• The practice had suitable safeguarding processes and staff knew their responsibilities for protecting adults and children.

• Patients’ needs were assessed and care was planned and delivered in line with current best practice guidance from the National Institute for Health and Care Excellence (NICE) and other published guidance.

• The practice provided preventive care and support to patients to ensure better oral health.

• Patients received their care and treatment from staff who enjoyed their work.

• There was no system in place to ensure that untoward events were analysed and used as a tool to prevent their reoccurrence.

• Systems to ensure the safe recruitment of staff were not robust, as essential pre-employment checks had not been completed.

• The provider had failed to address issues we had raised in our previous inspection such as the state of surgery flooring and confidentiality between the two surgeries.

• Complaints were not recorded adequately and there was no evidence to show they were used to improve the service.

• We received a number of complaints from patients about the practice who expressed concerns about the turnover of dentists and the cancellation of their appointments.

• There was no portable hearing loop to assist those who wore hearing aids. Information about the practice and patients’ medical histories was not available in any other languages, or formats such as large print. The practice did have access to translation services, but this was not well advertised to patients.

We identified regulations the provider was not meeting. They must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Establish and operate an accessible system for identifying, receiving, recording and responding to patients’ complaints

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:

• Review the management of sharps procedures and ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.

• Review protocols for the use of X-ray equipment taking into account Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment.