Updated 18 March 2022
We carried out this announced focused inspection on 15 February 2022 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 adviser.
To get to the heart of patients’ experiences of care and treatment,
We usually ask five key questions, however due to the ongoing COVID-19 pandemic and to reduce time spent on site, only the following three questions were 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:
- The dental clinic appeared to be visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- We highlighted issues relating to the risk management of Legionella, hazardous substances and sharps. An action plan and significant event reports were submitted following our visit to show how these areas had been addressed.
- 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.
- The clinical staff provided patients’ care and treatment in line with current guidelines. Systems to audit this could be improved.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- Staff and patients were asked for feedback about the services provided.
- The dental clinic had information governance arrangements.
Background
Albert House Dental Surgery is in Colne, Lancashire and provides NHS and private dental care and treatment for adults and children. The practice also has an NHS contract to provide orthodontic treatment.
There is level access to the rear of the practice for people who use wheelchairs and those with pushchairs. On street parking is available near the practice.
The dental team includes four dentists, an orthodontist, an orthodontic therapist, six dental nurses, one dental hygienist and two receptionists. The practice has five treatment rooms.
During the inspection we spoke with a dentist, the orthodontist, the orthodontic therapist, dental nurses, the dental hygienist, a receptionist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday, Wednesday and Friday 8.30am to 5pm
Tuesday 8.30am-5pm alternate early 8am to 5pm
Thursday 8.30am – 5pm alternate late 8.30am to 7pm
There were areas where the provider could make improvements. They should:
- Take action to ensure audits have documented learning points and the resulting improvements can be demonstrated.
- Take action to have an effective risk assessment for when the hygienist is not supported by a trained member of the dental team when treating patients in a dental setting taking into account the guidance issued by the General Dental Council.
- 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, ensuring validation testing is carried out and ongoing Legionella management.