J H Sager Limited - Compton

We carried out this announced comprehensive inspection on 6 March 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.
• The practice had infection control procedures which reflected published guidance.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to manage risks for patients, staff, equipment and the premises. Improvements could be made to the processes for checking electrical safety, prescription security and Legionella.
• 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.
• There was effective leadership and a culture of continuous improvement.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• Complaints were dealt with positively and efficiently.
• The practice had information governance arrangements. Improvements could be made to ensure staff make use of accredited interpreter services for patients who do not speak English as their first language.

Background

J H Sager Limited - Compton is in Harehills, Leeds 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. Street parking was available near the practice. The practice has made reasonable adjustments to support patients with access requirements, including a ground floor treatment room and a hearing loop for patients with access requirements. Staff made patients aware the toilet facilities were on the first floor and could only be accessed by stairs.

The dental team includes 2 dentists, 3 dental nurses, 1 practice manager and 2 receptionists. The practice has 2 treatment rooms.

During the inspection we spoke with both dentists, 2 dental nurses, 2 receptionists 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 to Thursday from 9am to 1pm and 1.30pm to 5pm

Fridays from 9am to 1pm

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

• Take action to implement any recommendations in the practice's Legionella risk assessment, 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.’

• Ensure there are systems in place to track and monitor the use of NHS prescription pads.

• Improve the practice's systems for checking and monitoring electrical equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, trailing wires and a broken electrical socket.

• Take action to ensure the availability of an interpreter service for patients who do not speak English as their first language.