Updated 11 August 2021
We carried out this announced focussed inspection on 29 June 2021 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 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 asked the following three questions:
• 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:
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 well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Courtyard Dental Care is inPontefract and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes one dentist, two dental nurses and a receptionist. The practice has two treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with the dentist and two dental nurses. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday from 9am to 5pm
Friday from 9am to 4pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines were available. Some items of the emergency equipment were missing.
- Improvements could be made to the management of the risks associated with Legionella and fire.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff provided preventive care and supported patients to ensure better oral health.
- Improvements could be made to the audit processes.
- Staff felt involved and supported and worked as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Take action to ensure staff have completed training in the detection and treatment of sepsis.
- 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.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken on all substances.
- Take action to ensure audits of radiography and infection prevention and control are undertaken at regular intervals to improve the quality of the service.