Coleshill Dental Centre

We carried out this announced inspection on 24 March 2023 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 CQC Inspection manager and 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.
• 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.
• Safeguarding processes were in place. Staff knew their responsibilities for safeguarding vulnerable adults and children.
• 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.
• Staff felt involved, supported and worked as a team.
• Staff and patients were asked for feedback about the services provided.
• Complaints were dealt with positively and efficiently.
• The practice had information governance arrangements.
• The practice had recently reviewed staff recruitment procedures to ensure that they reflected current legislation. These had not historically been applied consistently as not all required pre-employment checks were available for all staff.
• The practice had systems to manage risks for patients, staff, equipment and the premises. We found shortfalls in appropriately assessing and mitigating risks in relation to legionella. Immediate action was taken within 48 hours of our inspection to address most of these shortfalls.

Background

The provider is part of a group and has 9 practices, and this report is about Coleshill Dental Centre.

Coleshill Dental Centre is in Coleshill, Birmingham, and provides NHS and private dental care and treatment for adults and children.

The practice is accessed via a step from the high street. A portable ramp is available 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 access requirements.

The dental team includes 5 dentists, 1 dental hygienist, 1 dental nurse, 6 trainee dental nurses, 1 practice manager and 2 receptionists. The practice team are supported by an area manager, the group compliance officer, the practice owner and the chief clinical officer who all visit the practice on a regular basis. The practice has 5 treatment rooms.

During the inspection we spoke with the practice owner, 1 dentist, 2 dental nurses, 2 receptionists, the practice manager, the group compliance officer and the registered manager. We looked at practice policies, procedures, and other records to assess how the service is managed.

The practice is open:

Monday to Thursday 8.30am to 5pm

Friday 8.30am to 2pm

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

• Take action to implement any recommendations in the practice's Legionella risk assessment, 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.
• Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used.
• Implement an effective recruitment procedure to ensure that appropriate checks are completed prior to new staff commencing employment at the practice
• Improve the practice's protocols and procedures for the use of X-ray equipment in compliance with The Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2017 and taking into account the guidance for Dental Practitioners on the Safe Use of X-ray Equipment. In particular,ensure rectangular collimators are available for use in each treatment room.