We carried out this announced comprehensive inspection on 25 October 2022 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 adviser.
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 practice had infection control procedures in place; these did not reflect published guidance.
- Staff knew how to deal with medical emergencies. Recommended medicines and life-saving equipment were available, but not in the quantity recommended for some items.
- Systems to help manage risk to patients and staff were in place; equipment and premises checks ensured the safety of people who used the service.
- Safeguarding processes were in place and staff knew their responsibilities for safeguarding vulnerable adults and children. However, we observed that the practice safeguarding policy required updating, in that contact telephone numbers for local authority child safeguarding teams were out of date.
- Staff recruitment procedures were in place; not all required checks had been conducted.
- Patients were treated with dignity and respect and staff took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- Staff and patients were asked for feedback about the services provided.
- Systems were in place to deal with any complaints positively and efficiently.
- The dental clinic had information governance arrangements.
Glenlyon Dental Healthcare Limited is in Accrington, Lancashire and provides NHS care and treatment for children and private dental care and treatment for adults and children.
Access to the practice for people who use wheelchairs and those with pushchairs is possible. Staff can provide help to navigate a small step at the entrance to the practice. Car parking spaces are available near the practice.
The dental team includes the principal dentist, 2 dental nurses,1 of whom is a trainee, and 3 dental hygienists. The practice has 3 treatment rooms.
During the inspection we spoke with the principal dentist and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday, Tuesday, Thursday and Friday from 8.30am to 5.30pm.
We identified regulations the provider was not complying with. They must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Full details of the regulation the provider was not meeting are at the end of this report.
There were areas where the provider could make improvements. They should:
- Improve the practice’s sharps procedures to ensure the practice is in compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.
- 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, by ensuring staff have access to local rules for the X-ray equipment in each room.