Updated 26 January 2024
We carried out this announced comprehensive inspection on 3 January 2024 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 advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following 5 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 appeared clean and well-maintained.
- The practice had infection control procedures which generally reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were mostly available.
- The practice had systems to manage risks for patients, staff, equipment and the premises; , although improvements could be made to ensure all risks had been assessed and acted upon.
- 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.
- Clinical staff provided patients’ care and treatment in line with current guidelines, however improvements could be made to ensure clinicians took into account the guidance provided by the College of General Dentistry when completing dental care records.
- Patients were treated with dignity and respect. Staff took care to protect patients’ privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system worked efficiently to respond to patients’ needs.
- The frequency of appointments was agreed between the dentist and the patient, but improvements could be made to ensure clinicians gave due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved, 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 practice had information governance arrangements.
Background
The Dental Surgery is in Luton and provides NHS and private dental care and treatment for adults and children.
There is step free access to the practice for people who use wheelchairs and those with pushchairs by the provision of a portable ramp. Car parking spaces, including dedicated parking for disabled people, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 2 dentists, 5 dental nurses, 1 practice manager and 1 receptionist. The practice has 2 treatment rooms.
During the inspection we spoke with 2 dentists,1 of whom was the principal dentist, 2 dental nurses, the receptionist and the practice manager. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday – Thursday 9am until 6pm
Friday 9am until 5pm.
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice takes into account National Institute for Health and Care Excellence (NICE) guidance “Healthcare-associated infections: prevention and control in primary and community care" 2017.
- Take action to implement any recommendations in the practice's fire safety and legionella risk assessments and ensure ongoing fire safety and legionella management is effective.
- Implement an effective system for receiving and responding to patient safety alerts, recalls and rapid response reports issued by the Medicines and Healthcare products Regulatory Agency, the Central Alerting System and other relevant bodies, such as Public Health England.
- Take action to ensure the clinicians adopt an individual risk based approach to patient recalls taking into account the National Institute for Health and Care Excellence guidelines and take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.
- Implement audits for the prescribing of antibiotic medicines and for record keeping, taking into account the guidance provided by the College of General Dentistry.