Updated 12 October 2023
We carried out this announced comprehensive inspection on 19 September 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 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 reflected published guidance.
- Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
- The practice had some systems to manage risks for patients, staff, equipment, and the premises. However, we identified shortfalls in assessing and mitigating risks in relation to fire safety, prescription management and recording of accidents.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The practice had staff recruitment procedures which reflected current legislation, although this had not always been followed. Required pre-employment checks including references had not always been obtained for new staff.
- 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.
- There was effective leadership and a culture of continuous improvement.
- 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.
Background
Leicester Dental Solutions, also known as Winchester Avenue Dental Surgery, is in Leicester and provides NHS and private dental care and treatment for adults and children.
The services are provided by two individually Care Quality Commission registered providers at this location. This report only relates to the provision of general dental care provided by Dr Zeinab Attarwala. An additional report is available in respect of the general dental care services which are registered under Leicester Dental Solutions (MAQ53 Limited).
There is step free access to the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including dedicated parking for people with disabilities, are available near the practice. The practice has made reasonable adjustments to support patients with access requirements.
The dental team includes 6 dentists, 3 qualified dental nurses, 3 trainee dental nurses, 1 dental hygienist and 1 receptionist. The practice has 3 treatment rooms.
During the inspection we spoke with 1 dentist, 2 dental nurses and the receptionist. We looked at practice policies, procedures, and other records to assess how the service is managed.
The practice is open:
Monday from 8.30am to 7pm.
Tuesday from 8.30am to 7pm.
Wednesday from 8.30am to 7pm.
Thursday from 8.30am to 7pm.
Friday from 8.30am to 7pm.
Saturday from 8.30am to 7pm.
Sunday from 10am to 2pm.
There were areas where the provider could make improvements. They should:
- Implement an effective system for recording, investigating, and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.
- 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 for medicines management. In particular, improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use. Ensure all medicines that are dispensed include the practice’s address on medicines containers.