Updated 16 August 2021
We carried out this announced focused inspection on 13 July 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
Abbey End Dental Practice is in Kenilworth, Warwickshire 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 people with disabilities, are available near the practice.
The dental team includes six dentists, ten dental nurses, one decontamination nurse, two dental hygienists, three receptionists, one deputy practice manager and two practice managers. The practice has seven treatment rooms.
The practice is owned by an individual who is one of the principal dentists there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with four dentists, three dental nurses, one decontamination nurse, one dental hygienist and the deputy practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Friday from 9am to 5pm.
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. However, defibrillator pads had expired and were on backorder and one medicine was stored outside of refrigeration and the expiry date had not been adjusted to reflect this. These shortfalls were rectified following the inspection.
- The provider had some systems to help them manage risk to patients and staff. We found shortfalls in appropriately assessing and mitigating risks in relation to electrical wiring testing, radiography and air conditioning unit servicing. These shortfalls were rectified within following the inspection.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment policies which reflected current legislation. We found that the policy was not always followed as staff records we reviewed did not all have two references, photographic identification and hepatitis B immunity status retained. These shortfalls were rectified following the inspection.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- 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.
- Staff felt involved and supported and worked as a team.
- 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:
- Review the practice's systems for checking and monitoring premises maintenance taking into account relevant guidance and ensure that all services are well maintained. In particular ensuring that five-year fixed electrical wire testing and air conditioning unit servicing are completed within relevant timeframes.
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice. In particular ensuring two references, photographic identification and hepatitis B immunity levels are sought for newly recruited staff.
- 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 the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular, ensuring use of rectangular collimation when undertaking intraoral radiography to keep exposure dosage as low as reasonably practicable.