We carried out an announced comprehensive inspection on 23 March 2017 to ask the practice the following key questions; Are services safe, effective, caring, responsive and well-led?
Our findings were:
Are services safe?
We found that this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this practice was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this practice was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this practice was not providing well-led care in accordance with the relevant regulations.
Background
Dentcross Kidbrooke Village Dental Surgery is located in the London Borough of Greenwich. The premises are situated in a purpose-built surgery with two treatment rooms, a decontamination room, an X-ray room, a reception and waiting room, patient toilet, staff office and kitchen. The practice is fully wheelchair accessible.
The practice provides NHS and private services to adults and children. The practice offers a range of dental services including routine examinations and treatment, veneers and crowns and bridges.
The staff structure of the practice consists of a principal dentist, a dental nurse and a receptionist.
The practice opening hours are on Mondays to Fridays from 9.00am to 5.30pm.
The principal dentist is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons 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 inspection took place over one day and was carried out by a CQC inspector and a dental specialist advisor.
Thirty-six people provided feedback about the service. Patients were positive about the care they received from the practice. They were complimentary about the friendly and caring attitude of the dental staff.
Our key findings were:
- Patients’ needs were assessed and care was planned in line with current guidance such as from the National Institute for Health and Care Excellence (NICE).
- There were effective systems in place to reduce and minimise the risk and spread of infection. However, we noted some areas for improvement at the time of the inspection.
- The practice had effective safeguarding processes in place and staff understood their responsibilities for safeguarding adults and children living in vulnerable circumstances.
- Staff knew how to report incidents and kept records of these which the practice used for shared learning.
- There were arrangements in place for managing medical emergencies. However, some medicines had gone past their use by date, and needed replacing, at the time of the inspection.
- Equipment, such as the air compressor, autoclave (steriliser), fire extinguishers, and X-ray equipment had all been checked for effectiveness and had been regularly serviced.
- Patients indicated that they felt they were listened to and that they received good care from a helpful and caring practice team.
- The practice ensured staff maintained the necessary skills and competence to support the needs of patients. However, one member of staff had not had adequate safeguarding training at the time of the inspection.
- The practice had implemented clear procedures for managing comments, concerns or complaints.
- The provider had a clear vision for the practice and staff told us they were well supported by the management team.
- The practice had some governance arrangements and systems to monitor the quality and safety of the service. However, the practice had not effectively monitored and mitigated the risks associated with carrying out the regulated activities.
We identified regulations that were not being met and the provider must:
- Ensure systems are in place to assess, monitor and improve the quality of the service such as undertaking regular audits and ensuring that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Ensure an effective system is established to assess, monitor and mitigate the various risks arising from undertaking of the regulated activities.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Review the security of prescription pads in the practice and ensure there are systems in place to monitor and track their use.
- Review stocks of medicines and equipment and the system for identifying and disposing of out-of-date stock.
- Review the practice’s safeguarding training ensuring it covers both children and adults and all staff are trained to an appropriate level for their role and aware of their responsibilities.
- Review the practice’s infection control procedures and protocols taking into account guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.
- Review the current Legionella risk assessment and implement the required actions including the monitoring and recording of water temperatures, taking into account the guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance
- Review its responsibilities as regards to the Control of Substance Hazardous to Health (COSHH) Regulations 2002 and, ensure all documentation is up to date and staff understand how to minimise risks associated with the use of and handling of these substances.
- Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.