11 November 2021
During an inspection looking at part of the service
We carried out this announced focussed inspection 11 November 2021 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 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 three questions:
• Is it safe?
• Is it effective?
• 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 well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Borrowash Dental Centre is in the Borrowash area of the city of Derby and provides NHS dental care and treatment for adults and children.
There is level access into the practice for people who use wheelchairs and those with pushchairs. Car parking spaces, including those for people with disabilities, are available near the practice.
The dental team includes two dentists, two dental nurses including one trainee, one receptionist and a practice co-ordinator. The practice has three treatment rooms, two of which are located on the ground floor.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with dentists, dental nurses and the practice co-ordinator. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Thursday: 9am to 5pm, and Friday: 8:30am to 5pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Improvements should be made to the processes for cleaning dental instruments.
- 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.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- Improvements should be made to the risk assessment process for substances hazardous to health (COSHH).
- 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.
- The security of NHS prescription pads should be improved.
- Staff provided preventive care and supported patients to ensure better oral health.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols 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’. In particular review the processes used to clean and maintain dental instruments to make improvements where necessary.
- Improve the practice's processes for the control and storage of substances hazardous to health identified by the Control of Substances Hazardous to Health Regulations 2002, to ensure risk assessments are undertaken and the products are stored securely.
- Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.
- Take action to ensure the suitability of the premises and ensure all areas are fit for the purpose for which they are being used. In particular ensure a five-year fixed wire electrical safety check is completed.