26 October 2022
During a routine inspection
We carried out this announced comprehensive inspection on 26 October 2022 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 adviser.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five 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 was visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance. Not all recommendations made in the Legionella risk assessment had been actioned.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- 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.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Patients were treated with dignity and respect and staff 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.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The dental clinic had information governance arrangements.
Background
The provider has 27 practices and this report is about Westbury Downs Dental Care.
Westbury Downs Dental Care is in Westbury 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 disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with additional needs.
The dental team includes 1 locum dentist, 3 dental nurses (including 2 trainee’s), 1 dental hygienist, 1 dental nurse trainer, 1 receptionist, 1 practice support manager and 1 practice manager. The practice has 3 treatment rooms.
During the inspection we spoke with 1 locum dentist, 1 dental nurse, 1 receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Mondays to Saturdays from 8.30am to 5.30pm (Closed for lunch from 1pm to 2pm)
There were areas where the provider could make improvements. They should
- Take action to implement any recommendations in the practice's Legionella risk assessment, taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.’ For instance, thermostatic mixing valves or signage to indicate risk of scalding from hot water taps had not been fitted in patient bathrooms.