Antrobus Dental Surgery

We carried out this announced inspection on 15 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.

As part of this inspection we asked the following 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 not providing well-led care in accordance with the relevant regulations.

Background

Antrobus Dental Practice is in Sutton Coldfield, West Midlands 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 in the practice car park and on local side roads.

The dental team includes one dentist (the provider), one dental hygienist and four dental nurses, (one dental nurse is the practice manager; all dental nurses work on reception as needed). 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 provider, the dental hygienist, the practice manager and a dental nurse. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday, Tuesday and Thursday 9am – 5pm

Wednesday and Friday 9am - 2.30pm

Saturday - Closed

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures which reflected published guidance.
• A Legionella risk assessment had been completed by a competent professional, but the provider did not have access to this information.
• Staff knew how to deal with emergencies, training in basic life support was overdue but was booked for July. Appropriate medicines and life-saving equipment were available.
• The provider’s systems to help them manage risk to patients and staff could be strengthened and improved.
• There was no five-year fixed wire electrical safety certificate.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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.
• 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 systems for dealing with complaints positively and efficiently.
• The provider had information governance arrangements.

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

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

• Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.

• Take action to ensure the clinicians take into account the guidance provided by the Faculty of General Dental Practice when completing dental care records and improve the practice protocols regarding auditing patient dental care records to check that necessary information is recorded.