18 October 2022
During an inspection looking at part of the service
We carried out this announced comprehensive inspection on 18 October 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 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:
- The dental clinic was visibly clean and well-maintained.
- The practice had infection control procedures which reflected published guidance. Although evidence was not available to demonstrate that 2 staff had completed infection prevention and control training within the last 12 months.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had systems to help them manage risk to patients and staff.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children. Although evidence was not available to demonstrate that some staff had completed safeguarding training to the required level.
- The practice had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines. Some improvements were required to patient’s dental records to ensure all relevant information is recorded.
- 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.
- The appointment system took account of patients’ needs.
- There was effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team. Systems were in place for the appraisal of staff, but appraisal meetings were overdue for completion.
- Staff and patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The dental clinic had information governance arrangements.
Background
The provider has 155 practices and this report is about Cottam & Cottam.
Cottam & Cottam is in Harborne, Birmingham and provides NHS and private dental care and treatment for adults and children.
There is level 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 additional needs.
The dental team includes 5 dentists (including one specialist), 8 dental nurses (including 4 trainee dental nurses), 3 dental hygienists, 2 receptionists and a practice manager. The practice has 4 treatment rooms.
During the inspection we spoke with 2 dentists, 2 dental nurses, 1 dental hygienist, 1 receptionist and the practice manager. The Head of Clinical Compliance for Rodericks also attended this inspection. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday from 8.45am to 5.30pm, Tuesday, Wednesday and Thursday from 8.45am to 5.45pm and Friday from 8.45am to 3pm.
The practice had taken steps to improve environmental sustainability. For example, staff were requested to turn lights off when they were not in the room and were encouraged to recycle as much as possible.
There were areas where the provider could make improvements. They should:
- Take action to ensure the clinicians take into account the guidance provided by the College of General Dentistry when completing dental care records.
- Develop systems to ensure an effective process is established for the on-going assessment, supervision and appraisal of all staff. Including the training, learning and development needs of individual staff members at appropriate intervals.
- Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular ensure that the surgical drill used during dental implants is serviced in line with manufacturers requirements.