• Dentist
  • Dentist

Archived: The Dental Surgery

16 Southway, Newhaven, East Sussex, BN9 9LL (01273) 515562

Provided and run by:
Dr. Aileen Hopkins

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Background to this inspection

Updated 9 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008

The inspection took place on 4 October 2016 and was conducted by a CQC inspector and a specialist dental advisor. NHS England was also in attendance.

We had requested information from the provider regarding the breaches found at our last inspection on 22 June 2016. We reviewed information we held about the practice and information shared with us from NHS England following visits they carried out where issues were identified.

During the inspection we spoke with dentists, one qualified dental nurse and the practice manager. We did not speak with any patients on this occasion as the practice had voluntarily closed for seven weeks to enable improvements to be made.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

  • Is it safe?

  • Is it effective?

  • Is it caring?

  • Is it responsive to people’s needs?

  • Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Overall inspection

Updated 9 January 2017

CQC inspected the practice on 22 June 2016 and asked the provider to make improvements regarding Regulations 12 HSCA (RA) Regulations 2014 Safe care and treatment. Regulation 17 HSCA (RA) Regulations 2014 Good governance and Regulation 19 HSCA (RA) Regulations 2014 Fit and proper person. We took urgent enforcement action and the practice voluntarily closed for seven weeks to allow improvements to be made.

The Dental Surgery is a dental practice providing mostly NHS dental treatment 90%, with private treatment options for patients. The practice is located in the centre of Newhaven.

The practice has two treatment rooms, both of which are on the ground floor.

The practice provides dental services to both adults and children. Services provided include general dentistry, dental hygiene, crowns and bridges, and root canal treatment.

The practice’s opening hours are – Monday, Tuesday, and Thursday 9am to 5pm and Wednesday and Friday 9am to 12pm.

Access for urgent treatment outside of opening hours is facilitated by telephoning the practice and following the instructions on the answerphone message or by telephoning the 111 NHS service.

The principal dentist/owner is registered with the Care Quality Commission (CQC) as an individual. Like registered providers, they are ‘registered persons’. Registered persons 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 practice has two dentists; two qualified dental nurses, one student nurse, two receptionists, and a practice manager.

Our key findings were:

  • The treatment rooms were clean and had defined clean and dirty zones.
  • We found that some dental care records were not stored securely.
  • The building had been maintained to a suitable standard for a dental practice.
  • The practice carried out radiography practices in line with current regulations.
  • The practice followed the relevant guidance from the Department of Health's: ‘Health Technical Memorandum 01-05 (HTM 01-05) for infection control with regard to cleaning, storing and sterilising dental instruments.
  • There was a system to monitor training, learning and development needs of staff members which would be reviewed at appropriate intervals through the on-going assessment and supervision of all staff employed.
  • The practice’s infection control procedures and protocols are suitable giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum
  • 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’.
  • The practice had undertaken a Legionella risk assessment and implemented the required actions giving due regard to guidelines issued by the Department of Health - Health Technical Memorandum 01-05: Decontamination in primary care dental practices and The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’
  • An infection control audit had been undertaken.
  • The practice’s sharps handling procedures and protocols are in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
  • Audits of various aspects of the service, such as radiography and dental care records had been undertaken to help improve the quality of service.
  • Audit protocols have been implemented to document learning points which are shared with all relevant staff and ensure that the resulting improvements can be demonstrated as part of the audit process.
  • The practice is in compliance with its legal obligations under Ionising Radiation Regulations (IRR) 99 and Ionising Radiation (Medical Exposure) Regulation (IRMER) 2000.
  • The practice had arrangements for receiving and responding to patient safety alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS), as well as from other relevant bodies such as, Public Health England (PHE).
  • We saw that dental care products were stored in line with the manufacturer’s guidance and all were in date.
  • We saw that dental care records were not stored securely
  • Staff could demonstrate awareness of Gillick competency and were aware of their responsibilities.
  • All staff had completed training in the Mental Capacity Act (MCA) 2005 and were aware of their responsibilities under the Act as it relates to their role.

We identified regulations that were not being met and the provider must:

  • Ensure waste is segregated and disposed of in accordance with relevant regulations giving due regard to guidance issued in the Health Technical Memorandum 07-01 (HTM 07-01).
  • Ensure the storage of records relating to people employed and the management of regulated activities is in accordance with current legislation and guidance.
  • Ensure that specific training for IR(ME)R for one member of staff is completed by attendance on an external course.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

  • Review the practice’s protocols for the use of rubber dam for root canal treatment giving due regard to guidelines issued by the British Endodontic Society
  • Review the practice's protocols for completion of dental records giving due regard to guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping.
  • Review its responsibilities to the needs of people with a disability and the requirements of the equality Act 2010 and carry out a Disability Discrimination Act audit for the premises.