Cedarlea Practice Limited

We carried out this announced comprehensive inspection on 27 February 2024 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. Logs to demonstrate cleaning was completed on the non-clinical areas of the practice were implemented following this inspection.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Not all appropriate life-saving equipment was available, and some did not have expiry dates recorded. New equipment was purchased on the day of inspection. Staff were not keeping records to demonstrate that weekly checks were carried out on medical emergency equipment.
• The practice had some systems to manage risks for patients, staff, equipment and the premises. There was scope for improvement as we identified shortfalls in assessing and mitigating risks in relation to fire and legionella safety.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had staff recruitment procedures which reflected 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.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• Systems were in place to ensure complaints were dealt with positively and efficiently.
• The practice had information governance arrangements.

Background

Cedarlea Dental Practice is in Southam, Warwickshire 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 dentist, 3 dental nurses, including 2 trainee dental nurses, 2 dental hygienists, 1 practice manager and 2 receptionists. The practice has 2 treatment rooms.

During the inspection we spoke with 1 dentist, 1 dental nurse, 1 receptionist and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.

The practice is open: Monday from 9am to 5.30pm

Tuesday from 8am to 7pm

Wednesday from 9am to 8pm

Thursday from 9am to 5pm

Friday from 9am to 5pm

The practice is closed for 1 hour from 1pm to 2pm each day.

Saturday and Sunday Closed

The practice had taken steps to improve environmental sustainability. For example, sending text reminders of appointments to patients to reduce usage of paper, turning off lights when not in the room, general recycling of waste.

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

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

Full details of the regulation the provider was not meeting are at the end of this report.

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

• Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development.