Friars Walk Dental Surgery

We carried out this announced focused inspection on 27 April 2022 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 adviser.

To get to the heart of patients’ experiences of care and treatment, we usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were asked:

• Is it safe?

• Is it effective?

• 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 to be visibly clean and well-maintained.
• The practice had infection control procedures which mostly reflected published guidance.
• Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available. Although the glucagon was not always stored at the correct temperature to ensure it was effective.
• The practice had some systems to help them manage risk to patients and staff although there were shortfalls in the management of risk associated with recruitment, fire, legionella, sharps, maintenance of equipment, and Control of Substances Hazardous to Health for cleaning products.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The clinical staff provided patients’ care and treatment in line with current guidelines.
• Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• Staff felt involved and supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• The dental clinic had information governance arrangements.
• The provider did not have effective staff recruitment procedures to ensure staff were safe to work with vulnerable adults and children as not all staff had a recent Disclosing and Barring Service (DBS) check at the point of employment or evidence of satisfactory conduct in previous employment (references).

Background

Friars Walk Dental Surgery is in Dunstable and provides NHS and private dental care and treatment for adults and children.

There is level access to the practice via a ramp at the back of the practice for people who use wheelchairs and those with pushchairs. There is a car park for patients behind the practice. The practice has made some adjustments to support patients with additional needs.

The dental team includes three dentists, four dental nurses, two dental hygienists, one receptionist, an account manager, and a practice manager. The account manager and practice manager also work as dental nurses if needed. The practice has four treatment rooms, two waiting areas and two decontamination rooms.

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

The practice is open:

Monday to Friday from 9am to 5pm.

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:

• Take action to ensure dentists are aware of the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment.

• Take action to ensure audits of infection prevention and control, radiography, antimicrobial prescribing and record keeping are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.