The Care Quality Commission
  • Dentist
  • Dentist

High Street Dental Practice

11 High Street, Bedford, Bedfordshire, MK40 1RN (01234) 263000

Provided and run by:
Miss Raajvy Mukeshchand Shah

Important: The provider of this service changed - see old profile

All Inspections

30/09/2020

During an inspection looking at part of the service

We undertook a follow up desk-based review of High Street Dental Practice on 30 September 2020. This review was carried out to examine in detail the actions taken by the registered provider to improve the quality of care and to confirm that the practice was now meeting legal requirements.

The review was led by a CQC inspector.

We undertook a comprehensive inspection of High Street Dental Practice on 30 July 2019 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. You can read our report of that inspection by selecting the 'all reports' link for High Street Dental Practice on our website .

As part of this inspection we asked:

•Is it well-led?

When one or more of the five questions are not met we require the service to make improvements and send us an action plan (requirement notice only). We then inspect again after a reasonable interval, focusing on the area(s) where improvement was required.

Our findings were:

Are services well-led?

We found this practice was providing well-led care in accordance with the relevant regulations.

The provider had made improvements in relation to the regulatory breach we found at our inspection on 30 July 2019.

Background

High Street Dental Practice is in Bedford and provides mostly NHS and some private treatment to adults and children. Services include general dentistry and dental implants.

There is level access for people who use wheelchairs and those with pushchairs. There are no car parking facilities, these are available in local car parks within close proximity to the practice. They include car parking spaces for blue badge holders.

The dental team includes four dentists, four dental nurses who also undertake reception duties and a practice manager who also covers reception when required. The practice has three treatment rooms in use, all on ground floor level.

The practice is owned by an individual who is the principal dentist 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 review, we looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Friday from 8.45am to 5.30pm.

Our key findings were:

  • Significant event reporting had been subject to discussion by staff within the practice.
  • Monitoring arrangements had been improved to identify when staff training was due for completion.
  • There was evidence that recruitment processes had improved which was demonstrated when a new staff member was appointed.
  • The practice’s emergency equipment kit had been replenished to ensure that it reflected the Resuscitation Council Guidelines.
  • Whilst there was a sharps risk assessment, this required review to ensure it reflected the specific sharps used within the practice and the individual control measures.
  • Fixed wiring testing had been undertaken, including follow up remedial work required as a result.
  • Hepatitis B information had been obtained for a member of the team.
  • Rectangular collimators had been obtained for X-ray equipment in use.
  • Patient records held in paper form were now secured.
  • The Mental Capacity Act had been subject to some discussion amongst staff.
  • Patient referrals made were subject to monitoring.
  • The practice reception desk had been lowered; the practice had yet to implement other actions identified in an Equality Act audit previously completed.
  • Infection prevention control audits were not being completed with the recommended frequency as advised in national guidance.

There were areas where the provider could make improvements. They should:

  • Improve the practice's risk management systems for monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular, review national guidance regarding the recommended frequency of infection and prevention control audits and ensure that the sharps risk assessment is specific to the types of sharps held within the practice.
  • Improve the practice’s arrangements for ensuring good governance and leadership are sustained in the longer term. For example, the implementation of comprehensive policy in relation to significant events and monitoring actions to be taken as identified in audit.

30 July 2019

During a routine inspection

We carried out this announced inspection on 30 July 2019 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 CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five 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:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

High Street Dental Practice is in Bedford and provides mostly NHS and some private treatment to adults and children. Services include general dentistry and dental implants.

There is level access for people who use wheelchairs and those with pushchairs. There are no car parking facilities, these are available in local car parks within close proximity to the practice. They include car parking spaces for blue badge holders.

The dental team includes four dentists, four dental nurses who also undertake receptionist duties and a practice manager who also works as a receptionist when required. The practice has three treatment rooms in use, all on ground floor level.

The practice is owned by an individual who is the principal dentist 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.

On the day of inspection, we collected 15 CQC comment cards filled in by patients.

During the inspection we spoke with three dentists, two dental nurses and the practice manager. We looked at practice policies and procedures, patient feedback and other records about how the service is managed.

The practice is open: Monday to Friday from 8.45am to 5.30pm.

Our key findings were:

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance. Audits were undertaken annually rather than six monthly as recommended in national guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and most life-saving equipment were available with some exceptions. For example, child and adult self-inflating bags with a reservoir were not held and the oxygen cylinder held was the incorrect size. The provider purchased the self-inflating bags after the inspection.
  • The practice’s systems to help them manage risk to patients and staff required review as some were ineffective. Risks were not mitigated in relation to five-year fixed wiring testing and recommendations had not been implemented in relation to fitting rectangular collimators on X-ray machines.
  • The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
  • The provider’s staff recruitment procedures required review as they were not compliant with legislative requirements.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect. Not all paper patient records were stored securely, but following our visit, improvements were implemented.
  • Staff provided preventive care and supporting patients to ensure better oral health.
  • The appointment system took account of patients’ needs.
  • The provider asked staff and patients for feedback about the services they provided.
  • Patient feedback we received about the service was positive.
  • The provider dealt with one complaint positively and efficiently.
  • Governance arrangements required strengthening.

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/s the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

  • Review 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, undertaking audit activity every six months.
  • Review staff awareness of the requirements of the Mental Capacity Act 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
  • Review the practice's procedures to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner.
  • Review the practice's responsibilities to take into account the needs of patients with disabilities and to comply with the requirements of the Equality Act 2010.