University Dental Practice

We carried out this announced comprehensive inspection on Monday 24 July 2023 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 advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• 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 clean.
• The practice had infection control procedures which reflected published guidance. However, these were not always followed.
• Staff knew how to deal with medical emergencies. Not all appropriate medicines and life-saving equipment were available. All missing items were ordered following our inspection.
• We identified shortfalls in assessing and mitigating risks in relation to fire safety, legionella, prescription management and the safe handling and disposal of sharps.
• Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The practice had staff recruitment procedures which reflected current legislation.
• Clinical staff provided patients’ care and treatment in line with current guidelines.
• Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
• Staff provided preventive care and supported patients to ensure better oral health.
• The appointment system worked efficiently to respond to patients’ needs.
• The frequency of appointments was agreed between the dentist and the patient, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• The providers complaints policy required updating to include up to date information in relation to escalating complaints.
• Overall governance systems required strengthening and embedding with the practice team.

Background

University Dental Practice is in Cranfield and provides NHS and private dental care and treatment for adults and children.

There is a step to access to the practice with a narrow entrance door meaning the service is not easily accessible for people with restricted mobility, those who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.

The dental team includes 1 dentist and 1 dental nurse. The practice has 1 treatment room.

During the inspection we spoke with the dentist and the dental nurse. We looked at practice policies, procedures, and other records to assess how the service is managed.

The practice is open:

Monday to Thursday from 9am to 4pm.

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 the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.
• Implement an effective system for identifying, disposing and replenishing of out-of-date stock.