Updated 17 June 2021
We carried out this unannounced inspection on Wednesday 5 May 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.
As part of this inspection we asked:
• 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
Capehill Dental Surgery is in Smethwick, West Midlands and provides NHS and private dental care and treatment for adults and children.
There is ramped access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces are available near the practice on local side roads or in a pay and display car park which is a short walk from the practice.
The dental team includes three dentists, three dental nurses (including one trainee and a practice supervisor), and one receptionist. The practice has three treatment rooms, two of which were in use by the practice at the time of inspection.
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 Capehill Dental Surgery is the area manager.
During the inspection we spoke with one dentist, one dental nurse and the practice supervisor, who is also a dental nurse. The practice owner and registered manager attended for part of the inspection visit. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday from 9am to 6pm
Tuesday from 9am to 6pm
Wednesday from 9am to 6pm
Thursday from 9am to 6pm
Friday from 9am to 6pm
Saturday 9am to 1pm
Our key findings were:
- The provider had infection control procedures which mostly reflected published guidance. Ultrasonic protein and foil testing was not being completed at the required frequency. There was a ripped stool in use in the dental treatment room and inconsistencies were noted in the dating of pouched dental instruments.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff provided preventive care and supported patients to ensure better oral health.
- Staff felt involved and supported and worked as a team.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols 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’ (In particular repair or replace the ripped dental stool in the treatment room, complete validation and checks on the ultrasonic cleaner at the frequency recommended in the manufacturers guidance, pouched dental instruments should be dated in line with guidance. Storage of three in one tips should be improved, sharps boxes should be dated and signed with date of opening.
- Take action to implement any recommendations in the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Take action to ensure dentists are aware of the guidelines issued by the British Endodontic Society for the use of rubber dam for root canal treatment.
- Implement an effective system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.