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Dental Care Clinic Limited - Loughborough Road

Inspection Summary

Overall summary & rating

Updated 19 October 2020

We carried out this unannounced focussed inspection on 06 October 2020 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 CQC inspector who was supported by a specialist dental adviser.

We undertook an inspection in response to concerns received.

We asked the following question:

•Is it safe?

This question forms part of the framework for the areas we look at during a comprehensive inspection.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.


The practice is in the city of Leicester and provides NHS and private treatment to adults and children. The practice provides general dentistry services.

There is level access for people who use wheelchairs and those with pushchairs. There are no car parking facilities. Public car parking spaces, including some for blue badge holders, are available on side streets within close proximity of the practice.

The dental team includes four dentists, four dental nurses and one receptionist. The practice has three treatment rooms, two are on ground floor level. There is a separate decontamination facility.

The practice is owned by a company and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers 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 registered manager at Dental care Clinic Ltd – Loughborough Road is the principal dentist.

During the inspection we spoke with the principal dentist, three dental nurses and the receptionist. We looked at practice policies and procedures and other records about how the service is managed.

The practice is open: Monday to Thursday from 9am to 6pm and Friday from 9am to 5pm. The practice closes during lunchtimes between 1pm to 2pm.

Our key findings were :

  • The practice appeared clean and well maintained.
  • The provider had infection control procedures which reflected published guidance.
  • The provider had considered the risks presented by the Covid-19 pandemic and had implemented safety measures to protect staff and patients/visitors.
  • We looked at processes regarding fallow time in the practice and compliance with national guidance. The provider was following guidance issued.
  • We noted some areas for improvement at the point of our inspection, for example, ensuring antibiotics were stored securely and adequate monitoring for prescription pads.

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

  • Improve the security of NHS prescription pads in the practice and ensure there are systems in place to track and monitor their use.

  • Improve the practice's systems for assessing, monitoring and mitigating the various risks arising from the undertaking of the regulated activities. In particular ensure that robust risk assessment is completed if provider intentions are to deviate from national guidance.

Inspection areas


No action required

Updated 19 October 2020

Risks to patients

We found that the systems to assess, monitor and manage the risks to patient safety were working effectively.

The practice had undertaken risk assessments of the premises and for its staff in response to the risks presented by the Covid-19 pandemic. We saw physical changes made to the premises such as a locked front door policy, a screen placed at the reception desk, hand sanitization points and signage displayed for staff and patients.

Staff had access to suitable personal protective equipment (PPE) to enable them to work safely. This included fit testing of particle filtering masks for clinical staff. These particle filtering masks enable dentists to provide particular dental treatments to patients safely during the Covid-19 pandemic. We saw that an alternative powered air-purifying respirator (PAPR) hood was also available for use. Clinical staff had access to sufficient supplies of washable gowns, disposable gloves and other PPE as required. We saw that staff were wearing PPE at the time of our arrival at the practice.

We looked at the arrangements within the practice for fallow time when aerosol generated procedures were generated in particular dental treatments. We took into account national guidance, this included an updated version (2) issued on 2 October 2020 by the Faculty of General Dental Practice.

We looked at scheduled patient appointments involving aerosol generating procedures. We saw that adequate time was allotted following these treatments to enable a period of fallow time to take place. Staff we spoke with also confirmed the arrangements in place. We saw that signage was displayed on the surgery room door on the first floor to inform staff and visitors when fallow time was in operation. Prior to the release of the latest national guidance regarding fallow time, the provider had implemented measures to increase the number of air changes per hour in the surgery to reduce the recommended fallow time period. We noted that not all of the measures deployed at that time were based on proven scientific research or a robust risk assessment.

We looked at a selection of dental instruments held in surgery rooms. We noted that these were of suitable quality. We saw a stock of new instruments, these included endodontic files used for the purpose of root canal treatments and rose head burs for use with slow hand pieces. Staff told us that single use items were disposed of after their use and checks that we made supported this.

We saw that all instruments were pouched or were re-sterilised at the end of a session. Used instruments were soaked in the surgery and transported to the decontamination room in a suitable container. Staff we spoke with also confirmed the process they undertook. We observed the de-contamination process and processes followed by staff aligned with those recommended in national guidance. We did however note that temperature, steam, time (TST) strips for use in the autoclave were used once a day and not in every cycle. The principal dentist assured us that this would be rectified for future cycles.

We checked medicines and materials used and found they were within date for safe use. Patient records held in paper form were kept in cabinets inside a room that had a lockable door. This was away from the areas where patients/visitors would access. We were told that the door was locked at the end of each day. Clinical waste was also stored in a room away from where patients/visitors would access.

Safe and appropriate use of medicines

We saw that local anesthetic cartridges were full and were contained in blister packs.

We found that some antibiotics were stored in a lockable box along with records for when they had been individually dispensed. We also found antibiotics in a cupboard that had a faulty lock. The principal dentist told us these had recently been received by the practice. They moved them to a secure area following our discussion.

Whilst NHS prescription pads were held in a secure area, the monitoring logs maintained would not identify if any individual prescriptions had been taken inappropriately. Following our discussion with the principal dentist, we were assured that existing arrangements regarding prescriptions would be improved.


No action required

Updated 19 October 2020


No action required

Updated 19 October 2020


No action required

Updated 19 October 2020


No action required

Updated 19 October 2020