Updated 4 April 2023
We carried out this announced comprehensive inspection on 23 March 2023 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 reflected published guidance.
- Staff knew how to deal with medical emergencies. Not all medical emergencies equipment was available.
- The practice had systems to manage risks for patients, staff, equipment and the premises.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The staff recruitment procedure did not reflect current legislation. Not all staff had appropriate employment checks carried out before commencing employment.
- Clinical staff provided patients’ care and treatment in line with current guidelines.
- 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, giving due regard to National Institute of Health and Care Excellence (NICE) guidelines.
- There was effective leadership and a culture of continuous improvement. Audits of radiography had not been undertaken.
- Staff felt involved, supported and worked as a team, however there was no formal appraisal system in place for staff.
- Patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Dr M Gibbons and Associates Dental Surgery is in Wolverhampton 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. 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 5 dentists, 8 dental nurses (including 2 trainee nurses), 1 dental hygienist, 1 administrator and 2 receptionists. The practice has 5 treatment rooms.
During the inspection we spoke with 2 dentists, 4 dental nurses, 1 receptionist and the practice owner. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open:
Monday to Thursday from 9am to 1pm and from 2pm to 5.30pm
Fridays from 9am to 1pm and from 2pm to 5pm.
There were areas where the provider could make improvements. They should:
- Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice.
- Take action to ensure audits of radiography are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.
- Take action to ensure the availability of equipment in the practice to manage medical emergencies taking into account the guidelines issued by the Resuscitation Council (UK) and the General Dental Council.
- Take action to implement a staff appraisal system.