Updated 23 June 2021
We carried out this announced focused inspection on 25 May 2021 under section 60 of the Health and Social Care Act 2008 in response to information of concern recently received. 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 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 asked the following four questions:
• Is it safe?
• Is it effective?
• 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 this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services responsive?
We found this practice was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
My Dentist - High Street - Carcroft is in Doncaster 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 are available near the practice.
The dental team includes five dentists, six dental nurses, a dental hygiene therapist and four receptionists. The team is supported by a practice manager. The practice has three treatment rooms. The practice manager was supported by the company compliance lead during the inspection.
The practice is owned by a partnership and as a condition of registration must have a person registered with the CQC as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at My Dentist - High Street - Carcroft is the practice manager.
During the inspection we spoke with dentists, dental nurses, the practice manager and the compliance lead. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday and Wednesday 8am - 6pm, Tuesday 8am - 5:30pm,
Thursday 8am - 6:30pm and Friday 8am - 6:30pm.
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff.
- Legionella management systems were not operating in line with published guidance.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- A disability access audit was in place and the practice formulated an action plan to continually improve access for patients.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and 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.
- The provider had effective leadership and a culture of continuous improvement; clinical record keeping would benefit from effective auditing.
- Staff felt involved and supported and worked as a team.
- Staff awareness of Gillick responsibilities could be improved.
- The provider asked staff and patients for feedback about the services they provided.
- The provider dealt with complaints positively and efficiently.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Review the practice's Legionella management systems taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, Health and Safety Executive, HSG 274 Part 2 (2014) guidance 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: working with up-to-date guidance, identification of thermostatic mixing valves and temperature testing.
- Review the practice's protocols for completion of dental care records taking into account the guidance provided by the Faculty of General Dental Practice and Dental Record Keeping Standards: a consensus approach, published by NHS England & NHS Improvement (2019).
- Review staff awareness of Gillick competency and ensure all staff are aware of their responsibilities in relation to this.