• Dentist
  • Dentist

Cavendish Dental Practice

13-15 Derby Lane, Cavendish, Derby, Derbyshire, DE23 8UB (01332) 764997

Provided and run by:
Dr. Trishan Malhi

All Inspections

During an assessment under our new approach

We had previously undertaken a comprehensive inspection under our previous methodology of Cavendish Dental Practice on 20 September 2023 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We found the registered provider was not providing well-led care and was in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We undertook a follow up focused assessment on 5 June 2024. This assessment was carried out to review the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements. We found the practice had met regulations. The practice had systems to manage risks. Recruitment procedures reflected current legislation. Infection control procedures followed published guidance. There was effective leadership and a culture of continuous improvement. Cavendish Dental Practice is in Derby 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 8 dentists, 1 foundation dentist 7 dental nurses, 4 trainee dental nurses, 1 dental therapist, 1 practice manager and 2 receptionists. The practice has 7 treatment rooms. During the inspection we spoke with 2 dentists, 3 dental nurses, 2 receptionists the provider 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 from 8.45am to 7pm Tuesday from 8.45am to 5.30pm Wednesday from 9am to 4pm Thursday from 9am to 5.30pm Friday from 9am to 5pm

27 September 2023

During a routine inspection

We carried out this announced comprehensive inspection on 20 September 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 generally clean. We identified some areas that required repair and update to ensure they could be well-maintained.
  • The practice had infection control procedures which reflected published guidance. We found these were not always implemented effectively.
  • Staff knew how to deal with medical emergencies. Systems to ensure that appropriate medicines and life-saving equipment were available required improvement.
  • Practice systems to manage risks for patients, staff, equipment and the premises were not effective, specifically for fire safety and legionella management.
  • Safeguarding processes were in place, embedded into practice procedures 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.
  • 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.
  • 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

Cavendish Dental Practice is in Derby 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 8 dentists, 1 foundation dentist 7 dental nurses, 4 trainee dental nurses, 1 dental therapist, 1 practice manager and 2 receptionists. The practice has 7 treatment rooms.

During the inspection we spoke with 2 dentists, the foundation dentist, 3 dental nurses, 2 receptionists 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 from 8.45am to 7pm

Tuesday from 8.45am to 5.30pm

Wednesday from 9am to 4pm

Thursday from 9am to 5.30pm

Friday from 9am to 5pm

We identified regulations the provider was not complying with. They must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Full details of the regulation the provider was not meeting are at the end of this report.

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, that recommended processes are followed for manual cleaning of instruments and all work surfaces and furniture in treatment rooms are in a good state of repair and able to be cleaned satisfactorily.

  • 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 ensure audits of radiography and infection prevention and control 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.

During a check to make sure that the improvements required had been made

At our last inspection people who use the service told us staff were friendly and approachable and spoke to them in a respectful way. People we spoke with told us staff treated them with dignity and communicated well. One person told us 'I'm happy with the treatment I get here'.

People told us they felt the practice was clean and staff always wore gloves and other protective clothing to prevent cross contamination; this was confirmed by our observation on the day. We saw that the practice had systems to reduce the risk of infection. However we had a concern that not all staff were following the procedure fully. We saw evidence from the provider that this issue has been addressed.

11 January 2013

During a routine inspection

We spoke with people who used the service. They told us staff were friendly and approachable and spoke to them in a respectful way. People we spoke with told us staff treated them with dignity and communicated well. One person told us 'I'm happy with the treatment I get here'.

People told us they had discussed the treatment options available to them and felt they were able to make informed choices about their treatment. This showed that people who used the service understood the care and treatment choices available to them. None of the people we spoke with told us they had any difficulty in making appointments. One person told us 'I'm self employed so have had to rearrange a couple of appointments but they are very flexible'.

They told us they felt the practice delivered care and treatment in a way that met their needs. People told us they felt safe at the service and had never seen anything of concern.

People told us they felt the practice was clean and staff always wore gloves and other protective clothing to prevent cross contamination; this was confirmed by our observations on the day. We saw that the practice had systems to reduce the risk of infection. However we had a concern that not all staff were following the procedure fully.

People told us they had the opportunity to complete patient comment forms. We saw a patient information leaflet contained information about opening times, emergency contacts and the complaints procedure.