Updated 24 August 2021
We carried out this announced inspection on 10 August 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 always ask 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 providing well-led care in accordance with the relevant regulations.
Background
Deysbrook Lane Partnership is in West Derby, Liverpool and provides NHS and private dental care and treatment for adults and children.
There is level access to the practice via a portable ramp for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice.
The dental team includes seven dentists, six dental nurses, one of these being a trainee, two dental hygienists, a practice treatment co-ordinator and a practice manager. The practice has four treatment rooms.
The practice is owned by a partnership and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at Deysbrook Lane Partnership is the practice manager.
During the inspection we spoke with two dentists, two dental nurses 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, Tuesday and Thursday from 8am to 8pm and on Wednesday and Friday from 8am to 5.30pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- All required safety checks had been carried out at the practice. The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff. Some recommended monthly testing of the cone beam computed tomography X-ray equipment was not being carried out. We brought this to the attention of the provider on the day of inspection.
- 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 treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- 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 dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam (Computed Tomography). In particular, complete the routine monthly testing recommended for this equipment, using a phantom, as described in guidance.