Archived: Derwent Street Dental Practice

We carried out this announced inspection on 9 November 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

Derwent Street Dental Practice is in Consett 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, including dedicated parking for people with disabilities, are available near the practice.

The dental team includes the principal dentist, three trainee dental nurses (one of whom is also the practice manager) and one dental hygiene therapist. Reception work is carried out by the dental nurses. A visiting implantologist provides implant treatment. The practice has two treatment rooms, one of which is on the ground floor.

The practice is owned by an individual provider 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 practice manager, two trainee dental nurses and the dental hygiene therapist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open:

Monday and Thursday 8.30am to 4pm

Tuesday 9am to 6pm

Wednesday 8.30am to 5pm

Friday 8.30am to 1pm.

Our key findings were:

• The practice appeared to be visibly clean and well-maintained.
• The provider had infection control procedures which reflected published guidance.
• The provider had implemented standard operating procedures in line with national guidance on COVID-19.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were not available in line with guidance. We saw evidence that these were ordered on the inspection day.
• The provider had systems to help them manage risk to patients and staff. The systems for managing fire risk were not in line with national recommendations.
• The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider should review their staff recruitment procedures in line with current legislation.
• The clinical staff provided patients’ care and treatment in line with current guidelines, with the exception of options for periodontal treatment on the National Health Service (NHS).
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• The appointment system took account of patients’ needs.
• The provider had effective leadership and a culture of continuous improvement.
• 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:

• Take action to ensure that all clinical staff have adequate immunity for Hepatitis B or complete a risk assessment to mitigate the risk of working in a clinical role when the immune status is unknown.
• Take action to review the practice's fire risk assessment and ensure ongoing fire safety management is effective.
• Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. In particular, the provider should document a risk assessment for not undertaking a Disclosure and Barring Service check, and recruitment checks should be completed for agency or locum staff.
• Take action to ensure the clinicians take into account the guidance provided by NHS England and the College of General Dentistry when completing dental care records.
• Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.