Updated 19 January 2022
We carried out this announced inspection on 14 December 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 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
Portmore Dental is in Weybridge and provides 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 seven dentists, six dental nurses, 3 trainee dental nurses, two dental hygienists, two dental hygiene therapists, two treatment coordinators, a practice manager and four receptionists. The practice has eight treatment rooms.
The practice is owned by a company 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 Portmore Dental is the practice manager.
During the inspection we spoke with two dentists, five dental nurses, two dental hygienists, three receptionists, a company compliance lead 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 8am to 8pm
- Tuesday 8am to 8pm
- Wednesday 8am to 8pm
- Thursday 8am to 8pm
- Friday 8am to 8pm
- Saturday 9am 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.
- 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. However, improvements could be made to the Control of Substances Hazardous to Health (COSHH) file.
- 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.
- Ensure that the use of specialist equipment is in line with guidance.
- 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.
- Some patient care notes content could be improved in relation to guidance for specialist equipment.
- 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.
- Ensure that staff are correctly trained in relation to the use of specialist equipment.
- 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 processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- 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).
- Take action to ensure clinicians record in the patients’ dental care records or elsewhere the reason for taking X-rays, a report on the findings and the quality of the image in compliance with Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment or HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam (Computed Tomography) or the guidance on the safe use of Hand-held Dental X-ray Equipment.
- Implement practice protocols and procedures to ensure staff are up to date with their mandatory training and their continuing professional development, in particular 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).