Updated 7 February 2024
We carried out this announced comprehensive inspection on 16 January 2024 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 clean and well-maintained.
- The practice had infection control procedures which mostly reflected published guidance.
- Staff knew how to deal with medical emergencies.
- Improvements could be made to ensure appropriate medicines and life-saving equipment were available in line with current guidance and to ensure prescribed medicines were auditable.
- Risk management systems were not fully effective.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Improvement was needed to ensure staff recruitment checks were effective.
- 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.
- Leadership, oversight and management could be improved.
- Patient referrals to other dental and health care professionals were not monitored.
- The practice had systems for continuous improvement; not all audits followed current guidance.
- Improvements could be made to ensure staff felt involved and supported to provide feedback to leaders.
- Patients were asked for feedback about the services provided.
- Complaints were dealt with positively and efficiently.
- The practice had information governance arrangements.
Background
Poppleton Dental Practice is in York and provides 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 are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 3 dentists, 7 dental nurses (3 of whom are trainees), 2 dental hygienists and 1 receptionist. The practice has 3 treatment rooms.
During the inspection we spoke with 2 dentists, 3 dental nurses, 1 dental hygienist and the receptionist. We looked at practice policies, procedures and other records to assess how the service is managed.
The practice is open: Monday, Wednesday, Thursday and Friday from 9am to 5.30pm and Tuesday from 9am to 7pm. The practice is closed for lunch between 12.40pm and 2pm.
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 protocols for medicines management and ensure all medicines are stored and dispensed of safely and securely. In addition, the practice should ensure the emergency medical kit accurately reflects current guidance.
- Implement protocols for the use of closed-circuit television cameras taking into account the guidelines published by the Information Commissioner's Office.
- Implement a system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
- Take action to ensure audits of 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.